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A TEXT-BOOK 



DERMATOLOGY 



BY 



J. DARIER 



PHYSICIAN TO THE HOPITAL SAINT-LOUIS, MEMBER OF THE ACADEMY OF MEDICINE, PARIS, 
FRANCE ; HONORARY MEMBER OF THE AMERICAN DERMATOLOGICAL ASSOCIATION, ETC. 



AUTHORIZED TRANSLATION FROM THE SECOND FRENCH EDITION 



Edited with Notes by 

S. POLLITZER 



NEW YORK 

EX-PRESIDENT OF THE AMERICAN DERMATOLOGICAL ASSOCIATION; CORRESPONDING 

MEMBER OF THE FRENCH SOCIETY OF DERMATOLOGY AND SYPHILOGRAPHY, ETC. 



ILLUSTRATED WITH 204 ENGRAVINGS AND 
4 COLORED PLATES 




LEA & FEBIGER 

PHILADELPHIA AND NEW YORK 
1920 



Copyright 

LEA & FEBIGER 

1920 



MAR -4 1920 



g)CU559932 






PREFACE TO THE SECOND EDITION. 



The first edition of this book was exhausted several years ago. 
The Great War for some time absorbed all our activities and all 
our thoughts. But the time has come to think of the young physi- 
cians returning from the armies and make ready the means for 
facilitating the work they are called upon to perform. I have 
accordingly prepared this second edition, in spite of the difficulties 
of these troublous times. I have insisted upon its being entirely 
abreast of the progress of science and as complete as possible 
without unnecessary details. The general plan of the book, which 
has been tested and found to possess real didactic advantages has, 
of course, been retained. 

Many paragraphs have required rewriting and more or less con- 
siderable elaboration. Among these may be mentioned those deal- 
ing with anaphylaxis, phagedena, the sarcoids, the gangrenes, the 
cutaneous atrophies, inguinal epidermophytosis and the derm ato- 
my coses. The review of the general interpretation of tubercu- 
losis, congenital syphilis and the xanthomata has had to undergo 
notable modifications; paragraphs or new chapters have been devoted 
to the dyskeratoses, cutaneous diphtheria, the leishmanioses, the 
cutaneous leukemias, the tophi of gout, etc. The introduction of 
the serodiagnosis of syphilis and the treatment with the arseno- 
benzols into daily practice has demanded the allotment of con- 
siderable space to these subjects. Finally, in rewriting the 
therapeutic notes, I have endeavored to make them still more 
practical and to emphasize the recommendations dictated by my 
personal experience as to the choice of medication and the errors 
to be avoided. 

Professor Jadassohn, of Bern, has added to the German transla- 
tion of this book which appeared under his direction in 1913, -a 
considerable number of notes which I have carefully retained when- 



iv PREFACE TO THE SECOND EDITION 

ever his suggestions seemed to me to be of value for the reader; 
they have been incorporated in my text, of course, mentioning 
their origin. 

As it stands, this volume although rejuvenated and somewhat 
better nourished, remains essentially the same as its predecessor. 
I can only wish that it may meet with the same kind reception. 
My excellent and devoted publishers have left nothing undone to 
present it in good shape and I herewith express to them my sincere 
and grateful acknowledgments. 

J. Darier. 



EDITOR'S PREFACE. 



In undertaking the task of editing Darier's Precis de Dermatologie 
I have been actuated less by a personal friendship with the dis- 
tinguished author extending over a period of thirty years, than by 
a sense of the importance of introducing to the English-reading 
student of dermatology a work that is in many respects unique 
in its presentation of the subject and, as it seems to me, of extra- 
ordinary value for the student and the teacher. 

The plan of the work is fully explained in the author's introductory 
chapter and needs no further comment. The German translation 
of the first edition enjoyed the advantage of editorial comment at 
the hands of one of the foremost dermatologists of our time, Pro- 
fessor Jadassohn of Berne, and Darier has made use of these com- 
ments in this the second edition of his Precis. In preparing the work for 
English readers I have added notes which are enclosed in brackets, 
[ ] to differentiate them from the author's text and which, in 
the case of more extensive notes, are printed in a different style of 
type. It need not be emphasized that they are not intended by 
way of criticism: a few of them seemed to me desirable for the 
elucidation of the text; some were suggested by conditions peculiar 
to English and American practice and some convey my personal 
experience in clinical dermatology. It can hardly be expected that 
two dermatologists practicing their profession for thirty years in 
different hemispheres will be of the same mind on all subjects. 

There is no dearth of excellent treatises of dermatology in the 
English language and this work may confidently be expected to find 
its place beside them. The student cannot fail to profit from a study 
of Darier's unusual power of delineation in brief compass, his pre- 
sentation of clear-cut cameos of description, his obvious habit of 
thinking of lesions in relation to their anatomical structure and 
always with a background of general pathology. To these sufficient 



VI EDITOR'S PREFACE 

reasons for producing another book may be added the author's 
originality in the arrangement of his subject-matter and finally 
the desirability of placing before English-reading students the views 
of a foreign author, especially one who represents an old and honored 
school of dermatology. 

French dermatologists have played a leading role in the devel- 
opment of our science. The Hopital Saint-Louis, the greatest 
dermatological clinic in the world, has afforded an extraordinary 
opportunity for study and for more than a century it has furnished 
a succession of great dermatologists who have handed down their 
experience from teacher to pupil in an unbroken chain. Berne, 
Berlin, Breslau, Hamburg, London and many cities in America and 
elsewhere have excellent dermatologists whose observations and 
studies have greatly enriched our science; but in all these centers, 
dermatology is the work of one man or of a number of independent 
units. Vienna indeed furnishes an example of a school of derma- 
tology that has exercised a powerful and lasting influence in its 
field, lint Vienna was a one-man school and unfortunately the 
great light shed by Ilebra so blinded his followers that for a gen- 
eration the Vienna school suffered from a form of dermatological 
amblyopia: neither Duhring's disease, for instance, nor pityriasis 
rosea were recognized in Vienna as dermatological entities. French 
dermatology is unique in the peculiar circumstance of a familiarity 
with the great masters of the past that is almost personal. Alibert, 
Cazenave, Biett, Devergie, Bazin, Vidal, Fournier, Besnier, seem 
living personalities to the present-day student at the Saint-Louis. 
The advantages derived from this local continuity of observation 
and practice are inestimable. 

There is, however, an inherent danger bound up with its advan- 
tages; that is the danger of falling to too great an extent under the 
influence of tradition. Forty years ago French dermatology was 
suffering from the defects of its merits and it is only recently that 
such conceptions as are implied in the terms herpetism, arthritism, 
lynipliatism, etc., have ceased to sway French dermatological 
thought and traces of these conceptions still linger in French 
medical literature, side by side with the most advanced thought in 
medical science. 

Another possible effect of tradition may be found in the current 



EDITOR'S PREFACE Vll 

French dermatotherapy. French physicians to a great extent 
are in the habit of employing elaborate and complicated formulas 
in their treatment of diseases. Most of these have the sanction of 
long usage; some of them are even medieval in their construction. 
French dermatologists probably have not less success in curing 
their patients than those of other countries and it is surely not less 
interesting than instructive to learn that there are various ways of 
accomplishing this result. 

The observant reader will be struck with the great preponderance 
of references to achievements of French dermatologists. The 
assumption that this is an illustration of a narrow spirit which is 
out of place in a scientific work will be dispelled if the reader will 
examine an English, American, German or Italian text-book from 
the same point of view. He will find that this form of Chauvinism 
is common to all nations and is indeed perfectly natural. An author 
obviously will cite the literature with which he is most familiar 
and which is most accessible to his readers. From this point of view 
again it is an advantage to the English reader to become acquainted 
with the work of a foreign author and thereby acquire a broader 
outlook on his specialty. 

The Editor ventures to express the hope that this work of Darier's 

will be found not less useful to the reader than it has been instructive 

and inspiring to him. 

S. Pollitzer. 
New York, 1920. 



CONTENTS. 



Introduction 17 

Morphology of the Dermatoses 17 

Nosography of the Dermatoses 20 

Therapeutic Notes 20 



PART I. 
MORPHOLOGY OF THE DERMATOSES. 

CHAPTER I. 

Erythema and the Erythemata 23 

Intertrigo 30 

Erythema Solare seu Actinicum 32 

Erythema Pernio or Frost-bite 34 

Acro-asphyxia and Livedo 36 

Rosacea 36 

Erythema Multiforme 39 

Syphilitic Roseola 41 

CHAPTER II. 

Urticaria 43 

Giant Urticaria 49 

Urticaria Factitia, or Dermographism 49 

CHAPTER III. 

Purpura 52 

Secondary Purpuras 54 

Primary Purpuras 54 



CONTENTS 



CHAPTER IV 



Eczema (,0 

• - • • 79 



Artificial Eczemas 
Infantile Eczemas 

Secondary Eczematization §2 

Eczematosis go 

Dysidrosis gc 

Acute Disseminated Eczema or Miliary Impetigo .... 87 



CHAPTER V. 



Eczematides 



El{YTHEMATOTTS-SQUAMOUS DERMATOSES .... S9 



102 



Pityriasis Rosea of Gibert 

Psoriasis 

Parapsoriasis ,ji 

Psoriatiform Syphilides ijq 

Erythemato-squamous Epidermo-mycoses 114 



CHAPTER VI. 

Erythrodermas H5 

Primary Erythrodermas Hg 

Erythrodermic Dermatoses J20 

Secondary Erythrodermas 12i 

< fcragenital Erythrodermas and Erythrodermas of the Newborn 122 



CHAPTER VII. 

Papules and Papulae Dermatoses .... 127 

Juvenile Mat Warts j.,q 

Ldcherj Planus ,o. 

Atypical Forms of Lichen Planus yi-j 

Papules of Prurigo 140 

Papular Syphilides I e> 

Lichen Scrofulosorum j.r 



chapter viii. 

Vesicles and Vesicular Dermatoses . . 148 

Her P es '. 150 

Z,,n:i 154 



CONTENTS 



CHAPTER IX. 

Pustules and Pustular Dermatoses .... 160 

Impetigo 162 

Ecthyma 169 

Pustules of the Infectious Chronic Dermatoses 172 

CHAPTER X. 

Bullae and Bullous Dermatoses 174 

Accidentally Bullous Dermatoses 175 

Bullous Impetigos 178 

Pemphigus Acutus Febrilis Gravis 179 

Recurrent Pemphigus, Duhring's Disease or Polymorphous Dermatitis . 179 

Rare Dermatoses Related to Duhring's Disease 184 

Chronic Pemphigus 186 

Pemphigus Foliaceus 189 

Congenital Pemphigus 191 

Pemphigus Hystericus 192 

CHAPTER XL 

Keratoses 194 

Kerosis 196 

Pityriasis Simplex 19S 

Ichthyosis 200 

Ichthyosiform Hyperkeratoses 203 

Circumscribed Keratoses 206 

Keratoderma 211 

Keratosis of Mucous Membranes . . .218 

Dyskeratoses 230 

CHAPTER XII. 

Papillomatous and Proliferating Dermatoses . . . 237 

Venereal Warts 238 

Verruca Vulgaris 240 

Papillary and Pigmentary Dystrophy or Acanthosis Nigricans . . . 242 

Accidentally Proliferating Dermatoses 244 

Proliferating Tropical Dermatoses 249 

CHAPTER XIII. 

Tubercles and Tuberculo-ulcerative Dermatoses . . 252 

Tuberculo-Ulcerative Dermatoses 253 

Tubercular Sypbilides 253 

Lupus Tubercles 256 

Tubercles of Leprosy 258 

Cutaneous Sarcoids or Lupoid 259 



301 



CONTENTS 



CHAPTER XIV. 

Nodes and Nodules 263 

Nodular Dermatoses 263 

leute Nodular Dermatoses 265 

Gummas 266 

Subacute Non-gummous Nodes 271 

Sarcoids 272 



CHAPTER XV. 

In i rations, Ulcerative Dermatoses and Cutaneous Gangrenes 277 

Ulceration in General 277 

Acute Ulcerations 281 

Subacute Ulcerations 284 

Phagedena 293 

Ulcers 296 

Ulcerations of Mucous Membranes 303 

Cutaneous Gangrene 312 

CHAPTER XVI. 

Dyschromias 320 

Artificial ami Secondary Dyschromias 321 

Associated Dyschromias or Dyschromic Dermatoses 323 

Pigmentary Spots 323 

Diffuse Dyschromias and Melanodermas 325 

Vitiligo 329 

Tattoo Marks and Argyria 332 



CHAPTER XVII. 



Ci i wi.ni - Atrophies, Scleroses and Dystrophies 

< Beatrices 

Linear and Macular At rophies 
Idiopathic Atrophies 
Sclerotic Atrophies in Spots 

Scleroderma 

Regional Atrophies and I termatoscleroses 
( lutaneous I dystrophies 



334 
336 
341 
343 
346 
347 
353 
355 



CHAPTER XVIII. 

Cutaneous Hypertrophies 360 

Elephantiasis • 361 

Non-elephantiastic Hypertrophies 371 



CONTENTS 



CHAPTER XIX. 

Folliculoses 376 

Acute Suppurative Folliculitides 377 

Seborrhea 383 

The Acnes 384 

Cicatricial Depilating Folliculitides 392 

Subacute Folliculitides 395 

Pityriasis Rubra Pilaris 399 

Follicular Keratosis 401 



CHAPTER XX. 

Trichoses 404 

Hypertrichoses 404 

Alopecias 407 

Dystrophic Trichoses • 416 

Parasitic Trichoses 419 

Trichomycoses 428 



CHAPTER XXL 

Onychoses 430 

CHAPTER XXII. 

HiDROSES 441 

Functional Hidroses 442 

Organic Hidroses 445 



PART II. 
NOSOLOGY OF THE DERMATOSES. 



CHAPTER XXIII. 

Artificial Dermatitides ...... 447 

Dermatitides Due to Mechanical Causes 448 

Dermatitides Due to Physical Causes 450 

Toxidermas 456 

Toxidermas from External Causes 463 

Toxidermas from Internal Causes 471 



CONTENTS 



CHAPTER XXIV 



Neurodermatoses: Pruritus and Prurigo 481 

Primary Pruritus 483 

Prurigo 488 



CHAPTER XXV. 

Parasitic Dermatoses 502 

Dermatoses Caused by Insects 502 

Dermatoses Caused by Acari (Mites) 507 

Dermatoses Caused by Worms and Larvae 514 

Epklennoiiiycosos 515 



CHAPTER XXVI. 

[nfectious Dermatoses — Pyodermatitides . . 535 
Pyodermatitides 536 



CHAPTER XXVII. 

Infectious Bacillary Dermatoses 546 

Tuberculosis 546 

Leprosy 578 

Glanders 590 

Verruga Peruana 593 

Anthrax Malignant Pustule 593 

( Cutaneous Diphtheria 594 

Soft Chancre 596 



CHAPTEB XXVIII. 

Dermatomycoses 599 

Actinomycosis 599 

.Mycetoma or Madura loot 602 

Blastomycoses 603 

Sporotrichoses 605 



CHAPTEB XXLX. 

l.\Ki:cTiors Dermatoses due to Protozoa . . . 610 

Syphilis 610 

Yaws 646 

Leishmanioses 648 



CONTENTS 



CHAPTER XXX. 



Dermatoses of Leukemias and Analogous Pathological Conditions 651 

Cutaneous Leukemias 651 

Mycosis Fungoides 657 



CHAPTER XXXI. 

Tumors of the Skin 663 

Nevi 664 

Epithelial Tumors 669 

Vascular and Connective-tissue Tumors 689 

Sarcoma 706 



APPENDIX. 

Therapeutic Notes 711 



DISEASES OF THE SKIN. 



INTRODUCTION. 

This book is destined for new students entering a dermatological 
service and for general practitioners whose hospital recollections 
have become somewhat indistinct. My object has, therefore, been 
to make it as concise and practical as possible, while including the 
entire domain of cutaneous pathology. In order to make it short, 
I have been obliged to sacrifice the entire bibliography, historical 
references, quotations, learned discussions, etc., limiting myself to 
the essential data from the standpoint of diagnosis and treatment. 
In order to make it practical, it has seemed to me desirable to 
arrange the material according to a plan which is not customary 
and which I must first explain and justify. 

MORPHOLOGY OF THE DERMATOSES. 

In the first part (Chapters I to XXII) the eruptive lesions and 
the non-eruptive cutaneous changes, namely, the elementary derma- 
tological forms are discussed and to each of these a description of 
the principal syndromes in which the elementary forms occur is 
added. This requires some explanation. In dermatological prac- 
tice, the physician is confronted by very peculiar conditions. He 
does not have to look for pathological symptoms with the help of 
more or less complicated devices; the symptoms present themselves 
directly; he recognizes their features and their localization at once 
and witnesses this development. Under these conditions it seems 
obvious to me that a book intended to facilitate the study of skin 
diseases should accord the first place to morphology, namely, to 
what can be seen. In regard to the visible manifestations of cutan- 
eous pathology, two contingencies are possible: the condition may 
be an eruptive dermatosis, or the dermatosis under consideration 
may be non-eruptive. 

A. Eruptive Dermatoses. — This term is applied to skin diseases 
made up of efflorescences, namely, spots, papules, vesicles, etc. 
The analysis of every eruptive dermatosis must take up succes- 
2 



IS DISEASES OF THE SKIN 

sively four orders of facts: those relating to the efflorescence, to 
the eruption, to the disease and to the patient. 

1. The eruptive lesion deserves attention in the first place. This 
is in reality merely the anatomical lesion of the dermatosis as it 
appears to the naked eye. To inspect attentively an efflorescence, 
to palpate it, to scratch it, to compress it under a glass slide, to 
prick it with a needle so as accurately to determine its type — this 
constitutes in a general way the naked-eye study of the pathological 
anatomy. Conversely, it may be stated that to subject the efflores- 
cence to biopsy for the purpose of studying its histology means its 
clinical examination under the microscope. 

The efflorescences are of fundamental importance; they really 
represent the dermatologist's alphabet and no one ignorant of them 
can learn to read the skin. 

2. The eruption represents the efflorescences taken as a whole. 
It is visible and all its features are in evidence; it is necessary to 
note its abundance, its dissemination or its confluence, its topo- 
graphical distribution, etc. 

An eruption is said to be simple or pure when it is formed of 
lesions of the same kind and of the same degree of development; it 
is described as deformed, when the lesions are in different stages of 
evolution; it is called complex or polymorphous when it is made up 
of lesions of various types; complicated, when the primary lesions 
become associated with other lesions secondary and of another kind. 

:!. Information concerning the disease is usually furnished by 
inquiry; it is necessary to ask about the mode of onset, the preced- 
ing or accompanying circumstances, the extracutaneous symptoms, 
the course, etc. Direct examination, however, will often permit a 
series of data to be secured in this connection which will forestall the 
patient's answers and serve to control their accuracy. 

I. Among the conditions peculiar to the patient, some are of an 
objective kind; for example, the sex, the age, the race and the con- 
stitution of the individual. Information must also be obtained 
in regard to his occupation, his hereditary, hygienic and pathologi- 
cal antecedents, etc.; the viscera, body fluids and functions must be 
reviewed; briefly, a general clinical examination be carried out in 
order to ascertain the nature of the soil on which the skin disease 
develops. 

B. Non-eruptive Dermatoses.- In a second group of cases the 
physician is not confronted with an eruption. The cutaneous 
alterations may consist, for example, of a change in color of the 
skin, or dyschromia; in hypertrophy or atrophy; in a lesion of the 
nails, the hairs, etc. 

This altered appearance of the integuments can sometimes be 
referred with a high degree of probability to a definite inflamma- 



INTRODUCTION 19 

tory, degenerative or dystrophic pathological process. In other cases, 
however, it is impossible to determine the nature of the process. 
It therefore seems preferable to me to depend on what can be seen 
and to restrict oneself to classifying the pathological condition as 
it exists, instead of venturing into the ever-fluctuating domain of 
general pathology. 

The apparently extremely variable morphology of skin diseases 
can thus be brought down to various forms of eruptive lesions on the 
one hand and of pathological conditions of the skin on the other. 
I have combined them all under the name of elementary dermato- 
logical forms. For the description of dermatoses on the bases of 
their morphology, my work thus becomes reduced to the following: 

Selection of a certain number of elementary forms, easily dis- 
tinguished or recognized after very little study; description of these 
forms as accurately as possible, indicating the special anatomical 
lesions from which they result. 

Next, in view of the fact that these dermatological forms may be 
encountered in various cutaneous affections, it still remains to take 
up these affections one by one and to show what constitutes their 
individuality and on what their diagnosis is based. 

The dermatological types and cutaneous affections which can be 
approximated on the basis of their morphology are certainly not 
pathological varieties or diseases in the nosographic sense of the 
word, but are simple syndromes. Now these syndromes are of two 
different kinds. Some have an unknown or complex etiology 
(example: psoriasis); when they have been described with all their 
features, there is nothing more to be said. Others on the contrary 
are referable to a known specific cause (example: psoriatiform 
syphilides) and constitute one of the possible manifestations of a 
definite disease. The latter will have to be referred to again in 
the second part of this book and given their proper place under the 
general description of this disease. 

The first twenty-two chapters are accordingly dedicated to the 
principal elementary dermatological forms and to the syndromes 
derived from them. 

A classification of cutaneous diseases on the basis of their mor- 
phology presents this great advantage that the question of the 
diagnosis is presented under the same form in which it is met in 
dermatological practice. On the other hand, it is open to two 
principal objections. The first is this, that an attempt to take 
into account all the eruptive forms to which the same disease can 
give rise, would necessarily involve the splitting of its description 
into very many fragments. In order to avoid this difficulty, I 
have restricted myself in the first part to dwelling upon the most 
common and most characteristic syndromes; the others are briefly 



20 DISEASES OF THE SKIN 

mentioned so as to warn the reader against a possible mistake; 
their description will follow in the second part of this book. 

The other objection is that an arrangement based simply on 
clinical appearances can in no way constitute a classification. It 
lot- not claim to do so. Nobody would think nowadays of renew- 
ing the attempts of Plenke and Willan. It is generally conceded 
that the only logical and scientific classification in dermatology as 
well as in other branches of pathology is that which is based on 
etiology. 

NOSOGRAPHY OF THE DERMATOSES. 

In the second part (Chapters XXIII to XXXI) the point of view 
is entirely different. There I review the diseases of the skin itself, 
the pathological entities with a definite etiology, classified according 
to the nature of their cause. Hence there will be found: artificial 
dermatoses, 'parasitic dermatoses, infections dermatoses, etc. 

I have put into this class a group of skin diseases united, if not 
by a first common cause, at least by an identical phenomenon of 
;i general nature, namely, essential pruritus, dependent upon a 
nervous disturbance; this appears to be the second cause of the 
cutaneous manifestations. This group can be designated under the 
name of pruritus or neurodermatoses. 

I finally group among the pathological entities the tumors of the 
shin; admitting that in doing so I conform with custom rather than 
follow a personal conviction. The etiology of the majority of 
tumors is unknown or theoretical; it is for this reason no less than 
on account of their morphology and course that they have hitherto 
been considered as forming a natural group. 

The etiological classification of skin diseases is confronted with 
an insuperable difficulty. There exists a series of eruptions, by no 
means very rare or imperfectly characterized (for example, eczema, 
lichen, psoriasis) the etiology and pathogenesis of which are entirely 
unknown. The question arises what place should be assigned to 
these eruptions. The plan which I have adopted enables me to 
omit gratuitous hypotheses and avoid forced analogies. These 
eruptions, the causes of which are multiple, complex or unknown, 
;ire not diseases but pure syndromes. Their morphology is practi- 
cally all that is known about them. They have been described in 
the first part and do not require to be mentioned in the second. 

THERAPEUTIC NOTES. 

Although I have carefully indicated the attitude to be maintained 
by the practitioner in connection with each dermatosis, 1 have 
deemed it advisable to add a brief therapeutic review to this book. 



INTRODUCTION 21 

It contains the essential data required for dermatological treatment 
and the not very numerous prescriptions which it is indispensable 
to know. It frequently happens that these prescriptions are 
applicable to several classes of cutaneous affections; by uniting 
them at the end of the volume, I have avoided frequent repetitions. 

Imperfect as it is, this little book is the fruit of long experience. 
I have practised and taught dermatology for more than thirty 
years. The plan was conceived and the text frequently revised in 
the hospital. By this statement I do not mean to claim that all 
its contents are entirely original. In the expression of an opinion 
or in the rendering of a description, it is impossible, at least for me, 
to separate what is personal from what I have learned from teachers, 
from the literature and from associates. 

A book of this kind does not aim at replacing the classical treatises, 
but it is meant to serve as an introduction to and a summary of these 
larger works. 

J. Darier. 



PART I. 
MORPHOLOGY OF THE DERMATOSES. 



CHAPTER I. 
ERYTHEMA AND THE ERYTHEMATA. 

Erythema is a congestive redness of the skin, circumscribed or 
more or less diffuse, usually temporary, which disappears momen- 
tarily under pressure of the finger. Redness of the skin which does 
not comply with this definition, such as the following, is not desig- 
nated as erythema: 

Red spots resulting from the deposit of a coloring matter and dis- 
appearing on ablution. Peristent red spots of congenital origin, 
due to increase in size and number of the bloodvessels, but not to 
congestion; these are vascular nevi (p. 693). 

Red spots which do not disappear under pressure of the finger; 
these are cutaneous hemorrhages (III). 

Erythemas which are at the same time very extensive or general- 
ized and very persistent, are commonly designated by the name of 
erythroderma (VI). 

The term macules is reserved for erythematous and pigmentary 
but not cicatricial spots following on cutaneous lesions or eruptions 
of any kind (p. 322). 

Erythema is the first and most common skin reaction produced 
by an external or internal irritant. 

All acute eruptions and the great majority of chronic skin lesions 
are accompanied by reddening; this associated erythema is such an 
ordinary phenomenon that it only exceptionally requires to be 
taken into consideration. 

Simple, more or less irregular erythema constitutes the eruptive 
feature of a large complex group of dermatoses known as the 
Erythemata. The majority of these affections are so imperfectly 
characterized, however, that it is usually not an easy matter to 
determine whether a given erythema is a symptom or a disease, 



24 ERYTHEMA AND THE ERYTHEMATA 

making it impossible t<> describe these conditions separately. The 
following, therefore, applies indiscriminately to erythema and to 
the Erythemata. 

Varieties.— I >e] lending on the apparent pathogenesis of the cuta- 
neous congestion, it is customary to distinguish between active or 
arterial erythema, due to an increased blood supply, and passive or 
venous erythema, due to stasis. 

Ad I re erythema, resulting from a congestive or acute inflammatory 
hyperemia, is characterized by a bright pink color and a rise of local 
temperature. It is often accompanied by a sensation of heat or by 
itching. As a rule, it is ephemeral, lasting only a very few days. 

Passive erythema, on the contrary, produced by stagnation of the 
blood in the small cutaneous veins and capillaries, is of a darker or 
purplish-red color, the local temperature is diminished; it sometimes 
gives rise to a sensation of stiffness, with or without itching, and is 
generally more or less persistent. 

In a large number of cases, it is impossible to decide if an eryth- 
ema is active or passive. On the other hand, it is much easier to 
distinguish varieties, on the basis of whether the erythema is 
deformed; or from the configuration and duration of the eruption. 

An erythema is described as simple when the erythematous con- 
gestion is pure, that is, when the change of color of the skin is not 
complicated by any changes of its thickness, consistence and epi- 
dermic surface. Otherwise, the erythema is deformed. As a matter 
of fact, it frequently happens that the exaggerated hyperemia leads 
to secondary accessory lesions, which more or less modify the char- 
acters of the eruption; these must be interpreted as irregularities 
of the eruptive type. 

Erythematous congestion may thus become associated with: 
intradermic edema (urticarial erythema); cellular infiltration, 
manifested by a hard superficial elevation {papular erythema) or 
by deep-seated nodules (nodular erythema)', interstitial hemorrhage 
{purpuric erythema); early or delayed pigmentation (pigmented 
erythema ) ; raising of the epidermis in vesicles or bullae (vesicular and 
bullous erythema); finally furfuraceous or lamellar desquamation 
(squamous or desquamative erythema). 

These irregularities may be sufficiently marked to constitute 
intermediary or true transition forms, connecting the erythema 
with urticaria (II), papules (VII), nodosities (XIV), purpura (III), 
the dyschromias ( XVI ), bullous dermatoses (X), and erythrodermas 
(VI). Sometimes, real diagnostic as well as nosographic difficulties 
arise. 

When in doubt as to the classification of an eruption, either 
among the erythemata or among the dermatoses of another group, 
it is advisable to base one's judgment not exclusively on the objective 



THE ERYTHEMATA 25 

examination of a given eruptive feature, but on the eruption as a 
whole, its development and the nature of the underlying process. 
This rule, although excellent in certain cases, does not suffice in 
others; the following examples are illustrative. 

In the affection described by Bazin under the name erythema 
induratum of young girls, histology has shown the tissue-induration 
to be due to a tuberculoid infiltration. The nature of the patho- 
logical process here proves the condition to be not an erythema, 
but a hypodermic nodosity belonging to the tuberculides. The 
erythematous bullous eruption known as hydroa sometimes appears 
as an irregularity or a variety of polymorphous erythema, or again 
seems to be closely related to certain forms of bullous dermatosis. 
It is therefore differently classified by different authors. 

The configuration and extent of the erythema permit a distinction 
between the following types: 

Scarlatiniform or Scarlatinoid Erythema. — This is characterized 
by a more or less general, bright and uniform redness. The red color 
may result from confluence of miliary or lenticular hyperemic 
spots, or it may be diffuse from the start. The eruption is ephemeral 
or more or less prolonged; it is often of medicinal origin (mercury, 
quinin, opium, etc.), or due to infection (rash preceding smallpox 
or occurring in the course of gonorrhea, diphtheria, puerperal [and 
other streptococcic] fevers, indefinite infections) . There exists a rela- 
tively durable form, with general symptoms, recurrent desquamative 
scarlatiniform erythema, which connects this type of erythema with 
the primary erythrodermias. 

Rubeoliform Erythema. — This is made up of small, occasionally 
confluent spots, with ragged or diffuse margins, rarely slightly 
elevated; desquamation is absent or insignificant. The eruption is 
discrete, regional or generalized and of variable duration. The term 
roseola is employed for nummular or lenticular spots. Four groups of 
roseola are differentiated: 

(1) Roseolar exanthematic fevers (rubella, rubeola, seasonal roseola) ; 
(2) Symptomatic infectious roseola (syphilitic roseola, typhoid roseola 
or lenticular rose-spots, roseola of typhus, rash preceding small- 
pox, eruptions of cholera, cerebrospinal meningitis, certain septi- 
cemias) ; (3) Medicinal roseolas (Copaiva balsam, santol oil, turpen- 
tine, among the so-called balsam roseolas; the roseolas of quinin, 
antipyrin, odine, etc.); (4) Emotional roseola, which is not a true 
skin affection, but a physiological phenomenon. It consists of a 
transitory redness, arranged in spots or as a network, appearing 
over the chest, neck and shoulders of certain individuals on exposure 
of the person and identical with the emotional redness of the face. 

Erythema in Patches and Figured Erythema. — These consist of 
congestive spots, patches or surfaces of irregular shape, discoidal or 



2G ERYTHEMA AND THE ERYTI1EMATA 

of variable configuration (erythema marginatum or annulare, etc.). 
Although sometimes infectious, this type of erythema is more 
frequently of medicinal, serotherapeutic or autotoxic origin. 

The duration of an erythema, especially the active variety, is very 
short; as a rule, from one to four days at most. Some last much 
longer, however, for example syphilitic roseola. In certain forms, 
there is a marked tendency to recurrences. 

Congestive spots persisting for several months are sometimes 
designated as erythema perstans, but do not represent a definite 
pathological type. The presence of a manifestation of this kind 
should suggest conditions such as tertiary syphilitic erythema, 
lupus erythematodes, parapsoriasis, tuberculides, the spots of 
macular leprosy, premycotic erythema, and so forth. Under the 
name of centrifugal annular erythema, 1 have recently described an 
eruption which develops acutely, but nevertheless persists for many 
month- on account of the constant renewal of fresh lesions. The 
primary urticarial spots become rapidly transformed into rings, 
prominent and solid to the touch like cords; their peripheral exten- 
sion, which may amount to several millimeters daily and the frag- 
mentation of the rings, give rise to arches or strands whose design 
remains lightly pigmented. This form of erythema is peculiar and 
very rare; in the reported cases, it was situated on the buttocks, 
the back, and the thighs. 

Pathological Anatomy. — The clinical appearance of erythema, its 
configuration and the irregularities to which the eruptive element 
is subject, are explained to a certain extent by the pathological 
anatomy. The only essential lesion is the dilatation of the blood- 
i ssels of the cutis, more particularly those of the papillary body. 
It disappears in the cadaver and is usually no longer recognizable 
in cross-sections of microscopical specimens. 

The common rounded or oval configuration of the spots of active 
erythema is accounted for by the anatomical arrangement, this 
form being precisely that of the vascular territories of the skin 
supplied by the same afferent arteriole. Between these territories 
of direct supply, there exists an anastomotic plexus where the 
circulation of the blood is normally less active and where the blood 
has ;i tendency to accumulate in erythema due to stasis (livedo 
annularis). 

Intense congestion may give rise to exudation of blood plasma 
from the vessels (urticarial erythema) and to diapedesis of white 
corpuscles mixed with a few red blood cells. These elements are 
deposited as cuffs around the vascular branches, the inflammatory 
increase of the fixed cells contributing to the production of indura- 
tion and elevation (papular erythema I. 

The anatomical explanation of the pigmentation, phlyctenization 



THE ERYTHEMATA 27 

and desquamation, which are the possible results of erythema, will 
be found elsewhere. 

Etiology. — The causes capable of producing erythema are 
extremely numerous and varied. An attempt has been made, 
rationally enough, to group erythema on the basis of its etiology, 
but this leads merely to an incomplete and artificial classification, 
the condition representing as it does, not a disease, but purely a 
symptom. One identical cause may give rise to erythema of a 
variable objective appearance and course; on the other hand, the 
same form of eruption may depend on several different causes 
acting separately or together. In a number of cases, a factor of 
primary importance, known as predisposition is involved. 

The actual or immediate causes of erythema are either external 
or internal. 

External Causes. — Erythema from direct provocation; any slight 
traumatism causing local hyperemia. The passage of the nail over 
the skin causes the transitory appearance of a red line ; an exagger- 
ation of this phenomenon acquires a positive diagnostic value in 
certain cases {vasomotor or meningitic streak). Intertrigo-erythema 
is in part of mechanical origin. The effects of repeated friction will 
be pointed out under the heading of the artificial dermatitides 
(XXIII). Caloric and medicinal external erythema is discussed 
in the same chapter. Erythema a frigore and active erythema will 
be referred to presently. 

Bites or stings of the epizoa, lice, bugs, etc., of various insects, 
such as bees, wasps, hornets, mosquitoes and contact with the 
hairs of certain caterpillars or some plants, also give rise either to 
erythema or urticaria, of variable severity and extent in different 
individuals, or to a true inflammatory dermatitis. 

Internal Causes. — Erythema may make its appearance following 
the ingestion of certain foods or medicinal agents: the pathogenetic 
erythema of Bazin; or in the course of various infections, specific or 
ordinary: infectious erythema; or finally, under the influence of indi- 
vidual conditions of a nervous, autotoxic, dyscratic or unknown kind, 
constituting a predisposition or idiosyncrasy. 

Erythema of alimentary origin may be transitory and diffuse, 
occupying especially the face and the upper part of the trunk, or 
it may be more lasting. It assumes an urticarial or papular form, 
or that of a roseola or of marginate patches. All those food sub- 
stances which are usually prohibited in urticaria and eczema, have 
been held responsible; although some of these really possess a certain 
degree of toxicity, the majority act undoubtedly only with the assist- 
ance of indigestion, habitual dyspepsia, or rather that of a predis-. 
position which is now apt to be referred to anaphylaxis (pp. 460, 477) . 

Medicinal and serotherapeutic erythema belong under the heading 
of the toxidermas (XXIII). 



28 ERYTHEMA AND THE ERYTHEMATA 

Autotoxic erythema is the designation of conditions developing 
in uremia, gout, diabetes and hepatic diseases or in the course of 
acute or chronic appendicitis, obstinate constipation, etc. Such 
cases are referred to the production of autogenous poisons and in- 
sufficiency of the renal, hepatic, intestinal emunctories, etc. A 
popular belief to the effect that the skin under these conditions is 
damaged on account of the vicarious role it is made to play in sub- 
stitutiog the organs intended for the normal purification of the 
organism, is shared by a number of physicians, on what grounds I 
do not know. This idea is purely theoretical and rests on no reliable 
basis. 

Infectious erythema is observed in a large number of diseases, being 
due either to the specific microbe or to a secondary microbic associa- 
tion. As a rule, it is toxic infectious, the parasite acting apparently 
through the intermediation of its toxins or the resulting changes in 
the composition of the blood. Aside from the infections mentioned 
above, when speaking of roseola, mention must be made of the follow- 
ing, as capable of giving rise to erythema: Puerperal infection, ulcer- 
ative endocarditis, pneumonia, diphtheria, the anginas, vaccinia, 
gonorrhea, furunculosis, the pyodermatitides in general, etc. 

The possibility that a nervous influence by itself alone may give 
rise to erythema is demonstrated by emotional erythema, usually 
very transitory, produced by emotions such as shame, anger, joy, 
etc., on the face, the ears, the neck and sometimes the upper part 
of the chest (erythema a pudore). Abnormal psychic or nervous 
conditions, such as are met with at the time of the menopause, in 
exophthalmic goitre, etc., exaggerate this tendency to blushing, 
which in some patients is almost a real infirmity. 

The existence of reflex erythema of gastro-intestinal, urethral, 
uterine origin, etc., has also been admitted and it is naturally diffi- 
cult in such cases to distinguish between the role of the intoxication 
;iml t lie infection. 

Pathogenesis.- The pathogenetic mechanism is certainly not 
uniform in the group of erythema. Physiology teaches that hyper- 
emia is subject to vasoconstrictor and vasodilator mechanisms 
located in the bulbo-medullary center and at the periphery. These 
may become Involved in a very variable manner; by a local poison, in 
the case of a flea-bite; by a psychic disturbance in emotional eryth- 
ema. 1 difficulties arise in such common cases as when an individual 
is attacked by erythema, for instance, after eating mussels; the ques- 
tion is whether to interpret the erythema as directly toxic, auto- 
toxic through indigestion or of reflex nervous origin. Physicians 
used to hesitate between these theories and with good reason, for 
they are probably all wrong. In a patient in my service, who 
was attacked by urticaria under these conditions, the existence of 



THE ERYTHEMATA 29 

anaphylaxis was demonstrated by Ch. Flandin and Tzanck. At 
any rate, it is well to keep in mind that a series of experimental 
investigations, in harmony with the findings of pathological histology 
seem to prove that in the great majority of erythemas, those at least 
which are not absolutely transitory, the process involved is a local 
inflammation and not simply an angioneurosis, as had been assumed. 

In some instances of infectious erythema, the actual presence of 
microbes has been recognized in the skin. This is the case in the 
rose spots of typhoid fever, some forms of gonorrheal and pyococcal 
erythema and syphilitic roseola. When no microbes are found, it 
may be assumed that they have already disappeared. But it is 
extremely probable that in numerous cases the microorganisms 
act merely indirectly. 

Recently acquired knowledge of serotherapeidic erythema sheds 
some light on the pathogenesis of erythema in general. I shall have 
occasion, further on, to point out that the complication of serum- 
treatment must be interpreted as manifestations of anaphylaxis. It 
is probably not the anaphylactic poison itself, the apotoxine of Ch. 
Richet, which acts in the serum-eruptions. There is good reason 
to believe that changes in the composition of the blood are respon- 
sible, perhaps the presence of precipitins, as assumed by Hamburger 
and Moro, Marfan and Rovere, or perhaps other antibodies or 
derived substances of local origin, or disseminated by embolism. 

What is true for the serum eruptions is equally applicable perhaps 
to toxinic erythema and infectious erythema. We know that the 
injection of Koch's tuberculin into tuberculous subjects invariably 
produces a local erythematous patch, sometimes of erysipeloid 
type; in some cases it causes, moreover, the appearance of a general- 
ized eruption of more or less urticarial erythema. It is probable that 
in the last named cases the composition of the blood is different. 

In children suffering from severe diphtheria and treated with 
serum, there occurs not only an attack of urticaria or marginate 
erythema, but scarlatiniform and morbilliform erythema is likewise 
observed and the question arises if these eruptions are referable to 
the serum or are of infectious origin. 

The subject is complicated and not yet settled. What seems to 
be established is that in the pathogenesis of many forms of erythema, 
just as is true for certain urticarias, purpuras, etc., there is reason 
to admit the intermediation, between the pathogenic agent (foreign 
serum, microbe, toxine) and the eruption, of some change in the 
humoral composition of the blood. 

The ancient formulas in regard to the pathogenic factors of eryth- 
ema are thus peculiarly vindicated. I was right in asserting that . 
"while certain agents more or less readily produce eruptions in all 
persons, others necessarily require a predisposition and active co- 



30 ERYTHEMA AXD THE ERYTHEMATA 

operation of the organism/' E. Besnier correctly taught that "the 
apparent cause of the eruption sometimes seems to determine neither 
its form nor its course;" and that "the ordinary causes merely 
bring out the morbid tendency." It is thus understood why Brocq 
refused to group erythema among the true morbid entities, but made 
it one of the chief types of his "cutaneous reactions." Recent 
investigations serve to confirm these clinical observations. 

Prom all that has been said so far, it results that the few dermatoses 
of erythematous type, to be presently described, cannot be referred 
to a definite etiology and pathogenesis. It would be a much too 
simple as well as an erroneous conception of the subject to assume 
outright that intertrigo is an erythema of mechanical origin; that 
■sun hum, frost-bite, and livedo are dependent on a physical cause; 
that rosacea results from an auto-intoxication; or that erythema 
multiforme is infectious. These are not morbid entities, but simple 
syndromes. 

Syphilitic roseola is the only example I shall quote of an erythema 
having a definite cause, the eruptive manifestation of an actual 
disease. 

INTERTRIGO. 

The congestive redness which seems to result from mutual friction 
of two contiguous surfaces, is designated as intertrigo. This term 
should preferably be employed only as an adjective, attaching it 
to the name of the dermatosis produced by these conditions. As a 
matter of fact, aside from intertrigo-erythema, there exists intertrigo- 
eczema, etc. 

Intertrigo-erythema is ordinarily observed especially in obese 
individuals, in the fold between the buttocks and on the internal 
surface of the thighs, for example after a lengthy march. In stout 
women, it is also seen under the breasts, in the hypogastric fold, 
in the groin and axillary regions, or in newborn infants, on the 
buttocks, the folds of the neck, etc. 

Tlie more or less vivid redness is bounded by irregular or diffuse 
margins; there is local heat or pruritus; pigmentation and sometimes 
licheni/.ation finally develop. To the mechanical causes arc added 
the harmful effects of sweating, maceration, regional secretions, 
secondary fermentations and infections; so that the erythema is 
frequently complicated by dermatitis, lymphangitis, pyodermatitis, 
eczematous changes, etc., which may spread. 

The inguinal intertrigo of adults is distinguished from erythrasma 
(p. 532) and from the eczema marginatum of Hebra (p. 524) by its 
always symmetrically affecting the two sides of the fold, which is 
often fissured; and especially by the lesions of intertrigo being 



INTERTRIGO 



31 



neither uniform, nor polycyclic, nor marginate, having on the con- 
trary more or less diffuse borders. 

Infantile gluteal erythema is related to intertrigo and radiates 
from the intergluteal fold to the thighs, the back, the abdomen, 
even as far as the heels. It is extremely common and due not so 
much to friction as to contact of the skin with the dejecta, especially 
in the presence of diarrhea or athrepsia. Sometimes, the condition 
is a simple hyperemia, often of a coppery red color, covering a large 
area, or in patches; in other cases, the erythema is complicated by 
fissures or vesicles and oozing erosions, briefly by true eczematous 
changes (intertrigo eczema of the newborn) as shown by Marcel 
Ferrand; or again, it becomes covered by ulcerations and pyodermal 
lesions. 




Fig. 1. — Syphiloid (non-syphilitic) dermatitis of the buttocks in the newborn. 



In a form described under the name of 'payulo-lenticular erythema 
or yosterosive syphiloid by Sivestre and Jacquet, the erosions appear 
as raised, moist papules. 

Several varieties of these eruptions very closely simulate the 
polymorphous syphilides of the newborn, as may be seen from the 
illustration (Fig. 1) and the description of the latter. The diagnosis, 
in doubtful cases, rests on the general examination of the child and 
its environment, the direct discovery of the spirochete in the lesions, 
the Wassermann reaction of the little patient and its mother and 
finally on the course. As long as any doubt remains all precautionary 
measures must be taken to guard against contagion. 

The treatment of intertrigo consists in the frequent application 
of astringent or weakly antiseptic soothing lotions. An essential 
precaution is the successful separation of the affected surfaces, by 



32 ERYTHEMA AND THE ERYTHEMATA 

means of sterilized gauze, or especially by neutral mineral powders. 
Zinc oxide pastes are also appropriate, but salves are often injurious. 
The diet of children must be closely watched, and, if necessary, 
corrected. 

ERYTHEMA SOLARE SEU ACTINICUM. 

The inflammatory redness which follows after exposure to the 
rays of the snn is known as .sunburn. At the end of a few hours, 
the exposed surfaces, usually the face, especially the nose and ears 
and the hands, present an intense congestion, with swelling, burning 
and itching; this lasts a few days, then the epidermis desquamates 
in Large shreds and only a slight pigmentation is left behind. Not 
all individuals exposed to light radiations are affected to the same 
degree. Delicate skins, blondes, certain neuropaths and persons 
not accustomed to the open air, are more susceptible to sunburn, 
especially in the spring near the water, or in excursions on glaciers. 

Insulation, or heat-stroke, is an altogether different accident, 
sometimes very grave, characterized by general phenomena instead 
of cutaneous lesions and referable to a different pathogenesis. 

Solar erythema differs also from burns. It has been more than 
sufficiently demonstrated that it is not the caloric rays, but the 
chemical rays of the spectrum, the violet and ultraviolet rays which 
are responsible in these cases. The electric arc-light is accordingly 
capable of producing an entirely similar electric erythema. The same 
chemical radiations are utilized in phototherapy, for example in 
Finsen's method. 

A few very simple precautions, such as wearing a veil, the appli- 
cation of creams, lotions, or powders made with quinin or esculine, 
suffice to protect against sunburn. The treatment is that of an 
artificial dermatitis or a burn of the first degree. Numerous 
observers believe, not without good reason, that the action of the 
solar rays plays a part in the production of pellagrous erythema. 

Pellagra is a non-contagious general disease, endemic in many 
countries, notably in Italy (mal della rosa), where for a long time 
it has constituted a veritable scourge; in the Balkan provinces, in 
Spain, in southwestern France, in Egypt and in Asia minor. In the 
last ten years, important foci have been discovered in the United 
States, Guyana, the Antilles, and a few cases in Great Britain. 

Pellagra usually starts in the spring, followed by seasonal out- 
breaks. The erythema which often betrays its presence, manifests 
itself on the exposed parts, especially on the back of the hands and 
the wrists, sometimes on the face, neck, upper part of the trunk, and 
even on the dorsal aspect of the feet. It consists of a sombre redden- 
ing, with more or less clearly marked outlines, sometimes com- 
plicated by small bloody suffusions, fissures, or bullae. [The sharp 



ERYTHEMA SOL ARE SEU ACTINICUM 



:;:; 



line of demarkation between the affected areas and the normal skin 
is very characteristic of pellagrous erythema.] At the end of two 
or three weeks the skin becomes pigmented, darkens, and is shed in 
large shreds, finally undergoing atrophy, so as to resemble the skin 
in certain senile cachexias. Lesions of the mucous membranes are 
not infrequently observed, for example a bullous and later on 
diphtheroid stomatitis, as well as an analogous vulvitis. 

Aside from the cutaneous symptoms, a very marked loss of 
strength is noted after the onset of the disease, followed by a true 
asthenia, with serious digestive disturbances, anorexia, fetid diar- 
rhea, emaciation, sometimes chills and fever, ordinarily serious 



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Fig. 2.— Pellagra. Si 



r, Garrison and MacNeal, Thompson-McFadden Pellagra 
Commission. 



mental and nervous disturbances, paresthesias, hyperesthesias, 
convulsions, melancholia and delirium with a tendency to suicide. 
Many patients drift into insane asylums. The mortality in certam 
foci is appalling, but there are numerous abortive cases which may 
remain unrecognized. 

The theory according to which pellagra is due to a chronic intoxi- 
cation by spoiled maize (Zeism) has been widely accepted. It is 
claimed, however, that pellagra appears also in regions where maize 
(Indian corn) is never used. The infectious theory, which is now 
opposed to the maize theory, acquires much probability from recent 
epidemiological investigations, notably those of L. W. Sambon: 
Simulides or other insects are assumed to act as carriers of a special 
3 



34 ERYTHEMA AND THE ERYTHEMATA 

protozoan parasite, supposed to be the causative agent of pellagra. 
There would thus be a remarkable parallelism between this disease 
and malaria. [The etiology of pellagra is not clear but the weight of 
evidence at present would indicate that the disease is one of mal- 
nutrition due to a defective diet. The parallelism is rather with beri- 
beri than malaria. 1 1 >oubt prevails as to the nature of an absolutely 
identical or sometimes attenuated syndrome which may be observed 
in European countries among cachectic individuals, inebriates, 
or in those in a state of physical and moral deterioration. Some 
interpret this syndrome as a pellagroid erythema of alimentary or 
cachectic origin, whereas others admit no essential difference between 
this pellagroid and true pellagra. The point has not yet been settled. 

ERYTHEMA PERNIO OR FROST-BITE. 

Everybody knows frost-bite, in the form of a purplish and painful 
reddening frequently observed during the cold season, especially 

in children and youthful individuals. In order of frequency, these 
lesions affect the hands, notably the ulnar border and the fingers, the 
toes and heels, the ears, the nose and more rarely the cheeks. 

In thejirsf degree they consist of a swelling of the skin, which is of 
a dark or bluish-red color, tense, glazed, indurated and cold to the 
touch. Although the erythema is evidently due to stagnation, 
there occurs an instantaneous active hyperemia when the parts are 
too rapidly heated, the sensation of stiffness changing into an itching 
and very painful burning sensation. 

The erythema may be limited to patches, or diffusely outlined or 
even generalized over nearly the entire region. 

In the second degree, the frost-bite is "open," as it is ordinarily 
described. The ulcerations result either from cracks which appear 
in the folds, or from sometimes rather large bullae which originate 
on the swollen surfaces, probably under the influence of infection by 
pus-cocci. A persistent exudation follows, or a suppuration with 
crusts, which may lead to spongy bleeding ulcers, causing an actual 
lo>> of substance. Under these conditions, manual labor or walking 
sometimes become impossible. 

Untreated frost-bites usually last with exacerbations through the 
entile winter and disappear in the spring; but there are exceptional 
cases which persist even in the summer. 

The part played by the season and the local action of the cold are 
beyond dispute. However, the determining causes must not be 
allowed in overshadow the predominating importance of the soil. 
The age of five to fifteen years predisposes to frost-bite; but not all 
children are attacked, and moreover, cases are observed in young 
and adult individuals. Anemia, the so-called lymphatic constitu- 



ERYTHEMA PERNIO OR FROST-BITE 35 

tion and arterial hypotension, are evidently very often involved; 
it may even be stated that the frequently observed association of 
frost-bite with habitual acro-asphyxia, with adenopathies, with the 
scrofulous diathesis, might cause them to be classified among the 
manifestations of attenuated tuberculosis which are now designated 
as tuberculides (p. 563). This view is supported by the not uncom- 
mon cases where the frost-bite is apparently transformed into 
erythematous lupus, the chilblain lupus of Hutchinson; indicating a 
probable relationship between these two affections, the second of 
which is considered as a tuberculide (p. 571). The cases in which 
chilblains give rise to angiokeratoma, or alternate with papulo- 
neurotic tuberculide, point in the same direction. 

* Treatment. — In frost-bite of the first degree, the patient's suffer- 
ings are greatly relieved by means of lotions made with lukewarm 
or warm water, followed by rubbing with camphorated spirits, 
alcohol with a little iodin, or an infusion of tannic acid. Salves or 
powders made with tar or ichthyol are sometimes useful. 

In case of cracks or ulcerations, a moist occlusive dressing is 
applied, or applications of linimentum calcis or vasolanoline, 
until cicatrization is obtained, before resorting to astringents and 
keratoplastic agents, such as ichthyol, resorcinol, etc. 

Hydrogen peroxide in local baths of fifteen to twenty minutes, 
repeated two or three times daily, is often remarkably successful. 

The "biokinetic method" of Jacquet, provided it is properly 
applied, constitutes a preventive and excellent, treatment of frost- 
bite and chilblains. The patient must actively move (8 or 10 times 
daily for five minutes) all the joints of the affected extremities, 
which meanwhile are kept in an elevated position. 

General medicinal treatment, as employed in the lymphatic and 
scrofulous diathesis, must not be omitted, in the form of fresh air, 
dry or alcoholic rubs, cod-liver oil, arsenic, calcium, iodide of iron, 
etc. Certain forms of opotherapy are sometimes indicated (supra- 
renal extract, etc.). 

The disease known as trench-foot (said to be frozen feet), and 
frequently observed in the great war, differs from chilblains in many 
respects. It occurs in soldiers who have been obliged to stand 
several days in cold water or mud, even in the absence of ice, and 
is the result of the enormous withdrawal of heat, together with the 
effects of the [prolonged erect or] slanting position, the general 
fatigue and sometimes the constriction of the legs and feet. It 
consists of a purplish and very painful swelling, which interferes 
with walking, either without cutaneous lesions or accompanied by 
purpura, bullae, or even more or less extensive and deep sloughs. 
In such cases we have noted, with Civatte, a very persistent, pain- 
ful anesthesia of the distal end of the foot, indicative of peripheral 



36 ERYTHEMA AND THE ERYTHEMATA 

neuritis. Vascular lesions are held responsible by others. The 
duration may be several months, even in cases which receive proper 
treatment with baths or douches of hot air and kinetotherapy in 
the elevated position. 

ACRO ASPHYXIA AND LIVEDO. 

Acro-asphyxia and livedo are two other forms of passive erythema 
which musl be considered in connection with chilblains. 

Arm-asphyxia is a chronic congestion of the extremities, which 
an- of a purplish red color, habitually cold and often damp and 
flaccid. The ischemic spot produced by digital pressure requires a 
long time, sometimes nearly a minute, to resume its red color by the 
inflow of blood. 

This affection is observed under a variety of conditions. 
Obviously, this syndrome can be produced by a spasm of the veins, 
a change of the venous walls or a lowering of the arterial tension 
(cardiac or pulmonary lesions, cachexia). Permanent nervous dis- 
turbances, nutritional impairment and chronic exogenous or autog- 
enous intoxications may undoubtedly lead to the same result. 
Children or youthful individuals having the scrofulous diathesis 
are particularly susceptible. The manifestations are accentuated 
by cold. 

Without itself causing seriotis inconvenience, acro-asphyxia 
creates a scat of predilection for chilblains, tuberculides, angio- 
keratoma, artificial dermatitides and pyodermatitides and imposes 
;i sluggish, dragging tendency on the course of all these skin lesions. 

Livedo (livedo annularis a frigore or reticular asphyxia) has a 
practically identical etiology and significance. It is observed 
especially on the outer aspect of the forearms, arms and thighs, on 
the Hanks and sometimes over almost the entire integument. 

It consists <•!' a persistent purplish reddening, increased by cold, 
which appears on the skin as a network made up of strands of 
variable size, enclosing round or oval meshes. These meshes have a 
normal color and correspond to the territories of direct blood supply, 
whereas the strands of the network represent the anastomotic 
zones between these territories. Livedo accordingly represents the 
" negative" of a roseolar eruption. 

ROSACEA. 

Rosacea (acne rosacea, acne rosea, gntta rosea, Fr. couperuse) is 
;i 3pecial affection of the face, a passive erythema, persistent but 
variable, sometimes complicated by pustules. Its principal local- 
ization is the nose, the cheek and the middle of the forehead; by 
extension, it may reach the chin and the temples. 



ROSACEA 37 

Etiology. — Rosacea does not occur in children; it appears either 
after puberty, or more generally toward the age of forty or fifty 
years in women at the time of the menopause. It usually disap- 
pears in old age. 

Many different factors may enter into its etiology. It is very 
frequently preceded by a stage of acute congestion of the face, 
recurring in attacks and designated as erythrosis facialis; on the 
other hand, it almost invariably enters into the symptom-complex 
of kerosis (p. 196) with or without seborrhea. Both these morbid 
conditions act as intermediaries between the general disturbances 
presently to be enumerated and the chronic erythema of the face 
which we call rosacea. 

Most commonly, digestive disturbances are responsible, such as 
habitual constipation, gastro-intestinal fermentations, hepatic 
dyspepsia, abuse of stimulants, etc. Many people, especially young 
women, are subject to attacks of acute congestion of the face, 
diffuse or in patches, after eating too rapidly without sufficient 
chewing ( tachyphagia), or under the influence of certain foods or 
beverages. This facial erythrosis, which seems to be the effect of a 
reflex of gastric origin (L. Jacquet) may recur during several years, 
or it may change rather rapidly into rosacea. In other cases, rosacea 
is established from the start with persistent red spots which have 
a tendency to become confluent. This is apt to be the case in 
inebriates, especially wine-drinkers; the florid complexion and red 
nose are not a sign of splendid health, but rather an index of 
gastro-hepatic dyspepsia. 

Disturbances of the genital functions, especially utero-ovarian; 
the menopause; dysmenorrhea; inflammations of the tubes and 
ovaries; metritis, etc., likewise predispose to rosacea and especially 
to its localization on the chin. Chronic cardiac and pulmonary 
lesions are occasionally responsible. Affections of the nasal fossae 
and sinuses apparently invite the skin lesion in a number of cases 
and the same is true for dental caries, which through the loss of 
many teeth, moreover, becomes an important cause of dyspepsia. 

The action of cold, heat, or wind; the menstrual periods; cutaneous 
irritations of all kinds, contribute to the renewal of attacks and to 
the coalescence of the red spots, which become darker, of a purplish 
or dark blue color, or to the exacerbation of rosacea already estab- 
lished. 

Symptoms. — In its fully developed stage, rosacea consists of a 
persistent more or less diffuse redness, without elevation of the local 
temperature. After a while, superficial telangiectases make their 
appearance; small undulating veins ramify over the nasogenial 
grooves, furrow the wings of the nose and twist in intertwining 
twigs over the nose, the cheeks, the temples, the forehead, and the 



38 ERYTHEMA AND THE ERYTHEMATA 

chin. In well-marked cases of kerosis, the skin becomes swollen, 
thickened as n whole, and a few hypertrophied sebaceous glands 
may project over the surface. This condition in particular is desig- 
nated popularly as "gin-blossom." 

Although rosacea may run its course unmixed, it very frequently 
becomes complicated by folliculitis, especially in patients having 
seborrhea. The majority of authors have on the other hand inter- 
preted this acneiform folliculitis as primary and causative of the 
surface redness. Careful observation of these patients shows this 
to be incorrect. These follicular inflammations have also been 
generally confused with the papulopustules of acne vulgaris (p. 385). 
lima has shown that they differ from the latter by the absence of 
comedones, by their superficial situation, by their localization and 
by the age of the patients. 

The follicular inflammations of rosacea appear in attacks affecting 
from two to ten follicles at once; they pass through all the stages 
of papules, pustules, crusts, lasting from two to four days and are 
constantly repeated. Overindulgence in food, however, may give 
rise to a crop of twenty to thirty inflamed follicles. They aggra- 
vate the previous condition, unpleasantly affecting the patient's 
appearance and inevitably leaving at least a minute cicatrix. An 
extreme degree of rosacea seriously disfigures the sufferer. The 
purple pimply nose, deformed by swollen ridges separated by deep 
grooves, traversed by large dilated veins, is increased in size in all 
directions; this condition has been described as a separate affection 
under the name of rhinophyma (p. 374J. The other parts of the face 
are sometimes likewise purplish, swollen and scattered over with pus- 
tule-, cicatrices and telangiectases. The general impression is far 
from esthetic. 

Diagnosis. The diagnosis of rosacea is generally easy, except 
perhaps when it presents certain features suggestive of iodides and 
bromides, or of lupus pernio, which is by no means limited to the 
nose, or of lupus erythematodes, which is characterized by the 
sharp outline of its margins. The differentiation from certain ter- 
tiary syphilides of the middle of the face may prove extremely 
difficult. 

Treatment. In the first place, the various etiological factors 
referred to above must be looked for and appropriate diet and 
internal treatmenl prescribed. The local treatment varies with the 
degree of i he affecl ion and the presence or absence of complications. 
In ,i moderately >v\cw or mild case, the rule is to exhaust the power 
of topical agents before resorting to the obliteration of the dilated 
vessels. ( Ointments are often badly tolerated. Sulphur and ichthyol 
pastes, powders, bathing with lukewarm naphthol or ichthyol soap 
solution, sprays or warm lotions with astringent fluids with or with- 



ERYTHEMA MULTIFORME 39 

out the addition of bichloride are decidedly preferable. A sulphur 
and camphor lotion may by itself alone lead to considerable improve- 
ments provided the general indications have been met. Local 
massage, or better still, frequent sessions of facial gymnastics, advo- 
cated by L. Jacquet are often very efficient. Finally, when required, 
the treatment may proceed to obliteration of the telangiectases, 
preferably with the galvanocautery, or exceptionally by means of 
electrolysis or scarifications. 

In a grave case of rhinophyma, after relieving the irritation and 
checking the suppuration by the application of mild antiseptic 
sprays and dressings, surgical intervention may prove necessary 
in the form of nasal decortication. 



ERYTHEMA MULTIFORME. 

Under the name of multiform or polymorphous exudative ery- 
thema, Hebra distinguishes in the heterogeneous group of erythema 
a syndrome which one is almost tempted to regard as a disease. 
In its behavior it approaches the eruptive fevers, but as it is 
neither specific nor contagious, it must be described as pseudo- 
exanthematic. 

Symptoms. — The eruption, which is often accompanied by sys- 
temic phenomena, consists either of erythematous papular elements, 
or of vesicles or bullae, or finally of nodosities. It is somewhat 
uncommon to see these different forms of elements combined in the 
same individual. 

The following types may therefore be described : Papido-erythem- 
atous, which alone will be discussed here; a bullous type or hydroa 
(p. 175) and the so-called erythema nodosum (p. 265). Polymor- 
phous erythema of the papulo-erythematous type is characterized 
by nummular or lenticular congestive spots, the center of which 
promptly becomes cyanotic; these spots spread, remaining flat or 
becoming wheal-like or papular, sometimes discoid, or depressed in 
their center (Fig. 2). The livid color of the spots, their bright-red 
border, their manner of development and the distribution of the 
eruption are sufficiently characteristic. The lesions may also be 
whitish in their middle, appear to be bullous or actually become so 
in some cases; or again, their center may become purpuric. Their 
extension is rapid and sometimes gives rise to marginate spots, or 
even to rings, through the obliteration of the central area (erythema 
annulare). 

The eruption is composed of a very variable number of elements, 
disseminated or arranged in groups, sometimes confluent, usually 
symmetrical. The seat of predilection is the dorsal surface of the 
wrists, hands and forearms; it sometimes occurs on the fingers, the 



40 



ERYTHEMA AND THE ERYTHEMATA 



elbows, the nape of the neck, the forehead, the knees, and rarely 
the feet. Heat, pruritus and local tension are present, often regional 
swelling, sometimes arthralgias or even arthritis simulating acute 
articular rheumatism; prostration, headache, gastric disturbance 
and some fever at the onset. As a rule the eruption extends by 
successive attacks. The entire duration is from one to five weeks. 
Moderate desquamation is noted on its subsidence. 

Relapses are not uncommon; and Brocq finds in these relapses a 
connecting link between the recurrent cases with grouped lesions 
accompanied or not by especially painful phenomena and the 
painful polymorphous dermatitides (p. 179). 




pular type. 



Etiology.- Notwithstanding its appearance of a fairly well 
defined morbid entity, polymorphous erythema seems due to quite 
a number of ordinary causes. The effects of cold, alimentary or 
medicinal intoxications; infections, such as rheumatism, the anginas, 
gonorrhea, syphilis, tuberculosis, leprosy and perhaps reflex actions 
or auto-intoxications may all be present, without lending a special 
feature to the disease. In other words, the true cause is not known. 
It is probably a reaction of the organism under the influence of 
various intoxications or toxins. [There is reason to believe that 
low-grade infections are the most frequent etiological factor.] 

Treatment.- In the first place this must not be irritating. Accord- 
ing to the cases, purgatives, rest, a light diet may suffice; calcium 
chloride, aspirin and salicylates are often useful; iodides have been 



SYPHILITIC ROSEOLA 41 

highly recommended, but are rather injurious. Locally, applications 
of neutral powders will suffice, with protective dressings if needed. 

As it has been shown by the work of Prof. Landouzy and his 
pupils that polymorphous erythema in a considerable number of 
cases is due to tuberculosis, it is advisable to prescribe an appropriate 
hygiene for convalescent patients and to keep them under prolonged 
observation. 

SYPHILITIC ROSEOLA. 

No other infectious erythema possesses the same importance as ( 
syphilitic roseola; which is accordingly selected for a special descrip- 
tion. It is the most common of the cutaneous syphilides and con- 
sists of an eruption of spots, at first of a peach blossom color, of a 
deeper pink after a few days, of nummular size, rounded or oval 
shape and indefinite margins; these spots being at no time either 
squamous or pruritic. This eruption is scattered indiscriminately 
on the flanks, the chest, the back and the abdomen, sometimes 
extending to the neck, the limbs as far as the palms and soles, very 
rarely to the face where it is observed only on the forehead. 

In the absence of early and radical treatment, it usually appears 
from forty to fifty days after the chancre, beginning on the flanks 
and hypochondriac regions, developing in a fortnight and lasting 
from three to six weeks or two months. It occasionally fails to make 
its appearance even in cases where the chancre has remained 
unrecognized and no treatment has been instituted. Not infre- 
quently it escapes the patient's attention and must be looked for. 
Sometimes it is so profuse and high-colored as to give the skin a 
mottled appearance. 

The roseolar elements, especially when small, of lenticular dimen- 
sions, may cause a slight protuberance, as the result of some con- 
gestive edema; representing urticarial roseola. The form in which 
the macules develop into papular syphilides is designated as papular 
roseola. 

There may be a recurrence of the roseola in the course of the first 
or second year, or even later. These recurrent roseolas are usually 
rather pale and composed of larger and less numerous spots, which 
are often circinate or annular; their duration is apt to be prolonged. 

Tertiary roseola, or tertiary erythema, is the name given to dull red. 
non-squamous and non-infiltrated spots, polycyclic or circinate, 
occupying the trunk and limbs and very rebellious to treatment. 
These lesions are met with in long-standing syphilitic cases which 
have been subjected to energetic and prolonged treatment. They 
may be interpreted as the attenuated equivalents of tuberculo- 
ulcerative syphilides. 

Syphilitic roseola differs from the pityriasis rosea of Gibert and 



42 ERYTHEMA AND THE ERYTHEMATA 

from eczema by the absence of desquamation of any kind; from the 
balsamic roseolas, by its less intense color, its slow development and 
the absence of itching. Among the affections capable of causing real 
diagnostic difficulties may be mentioned the roseola of leprosy and 
the roseola of mycosis fungoides, but these are very rare and are accom- 
panied by other symptoms of these two diseases. Anti pyrin roseola 
is likewise objectively identical, but is the least common of anti- 
pyrin eruptions and lasts only eight to ten days. The most ordinary 
practical difficulty results from the macules sometimes remaining 
on the skin after a pyodermatitis, scabies, or pediculosis. All doubts 
will be cleared up by the history and the topographical distribution 
of tile lesions. 

Diagnosis. — The diagnosis of syphilitic roseola should always be 
carefully confirmed through the demonstration of other signs of the 
infection, such as glandular enlargement, mucous patches, remains 
of the chancre, alopecia, headache, etc., or by means of the ^Yasse^- 
mann reaction. 

Treatment. — Treatment should be prescribed only when the diag- 
nosis is positive; specific medication suffices, whereas irritating 
topical applications, sulphur baths and all methods which congest 
the skin, usually merely aggravate and prolong the eruption. 



CHAPTER II. 
URTICARIA. 

The name urticaria is applied to an eruption composed of peculiar 
elements which for lack of a special denomination are described as 
urticarial patches or papules or wheals. This eruption is essentially 
pruritic in character. 

The eruptive element of urticaria is an elevated distinctly outlined 
efflorescence, light pink in color or of an opalescent white with a 
pinkish areola; of a rounded or oval shape, sometimes polycyclic 
and of solid consistence. Its dimensions, usually nummular, vary 
from the size of a lentil to that of a more or less extensive surface. 

The eruption consists of an extremely variable number of elements, 
appears suddenly, in a few seconds, is transitory or ephemeral, 
vanishing after a few minutes or hours; the pinkish color fades, the 
elevation flattens out and, with some exceptions, no trace is left 
behind. 

The eruptive element is typical, but in spite of the characteristic 
eruption, urticaria can in no way be regarded as a disease. It is 
often a simple symptom, a cutaneous reaction which may be provoked 
by a great variety of causes. It is sometimes a syndrome, when the 
eruption assumes the behavior of a pseudo-exanthematic eruption 
and is accompanied by general disturbances; but it is not a disease 
in itself. 

It cannot be overemphasized that a fundamental characteristic 
of urticaria is that it is invariably associated with severe itching, 
heat or formication, so that scratching becomes imperative. The 
pruritus often precedes the appearance of the efflorescences; it is 
usually more diffuse than the eruption. 

In an attack of urticaria, the skin of the affected regions presents 
almost invariably, at any rate temporarily, a congestive tendency 
which may be designated as urticarism; owing to which new lesions 
may be provoked by scratching, rubbing, the action of cold or 
irritation of any kind. Jacquet has shown that no new lesions 
appear under really occlusive padded dressings. It may accordingly 
be stated that in urticaria the pruritus is primary as compared to 
the eruption. Many dermatologists therefore group urticaria under 
the heading of pruritus. 

The site of urticaria is extremely variable; it is localized or 
regional or it may be generalized; it affects preferably the trunk and 



11 



URTICARIA 



liml >s, but sometimes also the palmar and plantar regions, the face 
and the hairy scalp. In regions with a loose cellular tissue, such as 
the eyelids, the prepuce [the lips], etc., the eruption manifests itself 
in the form of an enormous urticarial edema, with diffuse margins, 
rather alarming, but transitory. 






Fig. 4. — Acute urticarial eruption, on the flank of an adult man (developing in the 
course of axillary pyodermatitis) . 



The mucous membranes may be invaded, notably the mouth, 
pharynx, and larynx; redness and edema occur, and the latter may 
interfere with respiration. Mention has even been made of urti- 
caria of the nasal fossae, the bronchi and the digestive apparatus. 
This is imaginary and merely a theoretical explanation of hay-fever, 
certain forms of asthma and of paroxysmal diarrhea. 

The general phenomena which may accompany the onset of certain 
very severe attacks of urticaria consist in fever, sometimes high 
but very transitory {urticarial fever) and prostration, with more or 
less marked digestive disturbances. 

Varieties. The varieties of urticaria are numerous and are 
derived from the morphological aspect of the lesions or the course 
of the eruption. The configuration of the eruptive lesions, discoid, 
annular, circulate or linear; as well as their porcelain tint, have no 
special importance. However, the center of the spots may assume 
;i purplish line, resisting digital pressure; this is hemorrhagic urticaria, 
separated merely by a shade from purpura urticans. The bloody 
infiltration in the skin in these cases undergoes the usual transfor- 
mation into pigment, so that the elevations leave brownish macules 
behind; this pigmented urticaria must be carefully distinguished from 
urticaria pigmentosa (p. 70o). 

The appearance of a small, hard and persistent papule in the center 



ETIOLOGY 45 

of the urticarial spots characterizes the papular urticaria of several 
authors. This is described in this book under the name of strophulus 
(p. 141). 

In certain very unusual cases, the urticarial elevations become 
topped by a blister containing a serous and later a purulent fluid 
which dries in crusts. This bullous urticaria is not readily distin- 
guished from certain forms of pemphigus (p. 175). [Both papular 
and bullous urticaria are not uncommon in the urticarias of infants 
and children.] 

The eruptions which have sometimes been described as urticaria 
perstans, the lesions of which persist for months or years, and which 
must not be confused with constantly recurring chronic urticaria, 
are probably related either to the prurigos (p. 498) or to the pre- 
mycotic eruptions (p. 657). 

Giant urticaria is a separate clinical form, which will be briefly 
discussed further on. The same remark applies to factitious urticaria. 

The behavior of urticaria permits the distinction of an accidental 
form, instantaneously produced by an external irritant; an acute 
form, in which the eruption consists of a single attack, or a few 
successive or overlapping attacks, so that the patient is well again 
in twenty-four hours, in two or three days, or in a week; and a 
chronic urticaria, in which successive attacks occur continuously, 
or at intervals, during months or even years. In the last named 
cases the itching becomes a real torment, disturbing sleep and 
exhausting the patient, as a result of the incessant scratching, the 
skin becomes covered with excoriations, crusts, and pigmentations. 
The condition may terminate, according to the age of the patient, 
in Hebra's prurigo, or in ordinary diffuse prurigo (pp. 494 and 496). 

Etiology. — The causes of urticaria are in part local, direct or 
determining; and in part general, indirect or predisposing. They 
may become associated in variable proportion in producing the 
eruption. 

It will be readily understood that a very active direct cause may 
by itself alone give rise to urticarial efflorescences, in all persons 
indiscriminately; on the other hand, in very strongly predisposed 
individuals, the most ordinary and trifling irritant may produce the 
eruption. Between these two extremes all variations are met with. 

Authors who maintain that urticaria should be considered as a 
disease having a deep-seated cause in the organism, refuse to include 
with it such artificial efflorescences as that produced, for instance, by 
the stinging nettle, although the very name of the disease is derived 
from that plant [urtica]. This conception has certain arguments 
in its favor, but I cannot accept it for the reason that the eruption is 
identical in urticaria of external and of internal origin and that it is 
impossible to draw a sharp line between these two affections. All 



46 URTICARIA 

urticarial eruptions are therefore grouped together in this book 
under the heading of urticaria. 

External Causes. — Stings produced by the glandular hairs of 
nettles, the stings of mosquitoes, bed-bugs and fleas, contact with the 
hairs of processional caterpillars, with medusae, or various poisonous 
plants, give rise after a few seconds to severe pruritus and slight 
reddening. Next, especially on scratching, or when the congested 
and sweaty skin is washed with cold water, an eruption of accidental 
urticaria, or even of acute generalized urticaria in predisposed 
individuals, occurs. A local cause should therefore be looked for 
in the first place in cases of urticaria as in any pruritus. 

It is superfluous to enumerate all irritants capable of inducing the 
eruption in temporarily or permanently susceptible individuals. 
The slightest friction or contact with water or even air may be 
sufficient. 

Internal Causes. — Clinical studies of the manifold conditions 
under which urticaria is observed, has led to the following conclu- 
sions: The predisposing factor in urticaria was supposed to be 
referable to somewhat indefinite nervous states, often of congenital 
origin in children and youthful individuals, of acquired origin in 
adults, due to mental strain, hysteria, neurasthenia, chronic intoxi- 
cations, or weakening from any disease. Violent emotions, anger, 
or fear, may precipitate a crisis. 

Digestive disturbances play the principal part in other cases, 
especially gastric dyspepsia, dilatation of the stomach, diseases of 
the liver, habitual constipation. An attack of indigestion, or par- 
taking of certain foods or drinks, brings on the eruption in some 
individuals, the following substances appearing particularly injur- 
ious; Deep-sea fish, crustaceans, shellfish, especially mussels, pork, 
game, eggs, preserves, cheese, ices, strawberries, raspberries, wines, 
tea and coffee, many medicinal agents, etc. 

In urticaria ab ingestis, a reflex action of gustatory or gastric 
origin has sometimes been assumed on account of the very brief 
period before the onset of the attack. The reflex may perhaps also 
start from the genito-urinary organs, according to the older views. 

The urticaria from abnormal intestinal fermentations, from renal 
or hepatic insufficiency, from gout, pregnancy, etc., was interpreted 
as autotoxic, while the urticarial eruption which sometimes precedes 
or accompanies the eruptive fevers, intermittent fever, etc., was 
considered as infectious urticaria. 

It was known finally that several varieties of urticaria may occur 
in blood diseases, leukemias, etc. 

Jn the last few years, however, the subject has taken on another 
aspect through laboratory and experimental investigations along 
the line of anaphylaxis (p. 460), as will be discussed further on. 



PATHOGENESIS 47 

The fact has now been established that the majority of urticarias 
are due to anaphylaxis. 

Pathogenesis. — The eruption of urticaria obviously results from a 
local congestion of the cutaneous vessels with serous exudation espe- 
cially in the papillary body, sometimes extending to the hypoderm 
and more rarely to the epidermis. The firmness of the urticarial 
wheal, its pallor resulting from the compression of the bloodvessels 
and the cleavage of the epidermis in the bullous form are proof that 
the plasma is exuded under high pressure. 

It should be kept in mind that toxic or infectious erythema may 
be urticarial, so that no sharp line can be said to exist between the 
two eruptive types of erythema and urticaria. Histology furnishes 
no data to explain the phenomenon of urtication. In simple primary 
urticaria, an excised segment usually presents no lesion, provided 
the blood-pressure and edema have disappeared ; sometimes, a slight 
local polynucleosis is noted. [Gilchrist has found distinct evidences 
of inflammatory changes even in the most recent wheals.] 

As to the pathogenic mechanism, Torok and Vas have shown that 
the fluid exudate in urticaria contains more albumin than that of 
the mechanical edemas and is analogous to that of the inflammatory 
exudates. The inflammatory or angioneurotic character of the 
urticarias has been discussed by several foreign authors. Torok 
and Philippson successfully produced experimental urticaria in 
dogs, by inserting into the cutis capillary tubes filled with various 
substances among which may be quoted: peptones, pepsin, trypsin, 
cadaverin, putrescin, morphin, atropin, antipyrin, antidiphtheritic 
toxin, staphylococcus toxin, etc.; hot water, formic, oxalic and uric 
acids, syntonin, casein, etc., are said to be less active; while glyco- 
coll, asparagin, purin derivatives, bilirubin, etc., are apparently 
inactive. Possibly some of these substances which act in concen- 
tration also play a part when they circulate in even infinitesimal 
dilution in the blood. 

More widely applicable and more conclusive are the experiments 
which have demonstrated the anaphylactic character of the major- 
ity of urticarias. For those which are produced by the sera (page 
477), proof has been furnished by Arthus, Theobald Smith and 
others. Reasoning by analogy, the same mechanism has been 
invoked in all cases where injection or absorption of a foreign 
albumin enters into consideration. Widal, in collaboration with 
Abrami, Brissaud and Joltrain, has shown that in an attack of 
alimentary urticaria, the cutaneous phenomena are preceded by 
a set of blood and vascular phenomena, an actual "hemoclastic 
crisis," identical with that of anaphylactic shock; a fall of blood- 
pressure and a rapid leukopenia being its essential features. More- 
over, the transmission of passive anaphylaxis to guinea-pigs has been 



48 URTICARIA 

successfully carried out by Bruck, for urticaria due to pork, and 
for the eruption following mussels, by Flandin and Tzanck working 
in my laboratory. The watery fluid of hydatid cysts, which causes 
urticaria and sometimes grave symptoms when effused into serous 
cavities, although it is not poisonous has been shown to produce 
anaphylaxis, by Chauffard, Boidin, Laroche and Deve. 

Tims it becomes extremely probable that under a large number 
of conditions, the susceptibility to urticaria consists in an ana- 
phylactic state and that the determining cause merely liberates 
the eruption. 

Treatment. — In the first place, it is necessary to determine that 
the urticaria does not depend upon an external cause, parasitic 
or other. Acute attacks are suggestive of some article of food; 
and a purgative and a strict diet based on the list of presumably 
harmful substances (see Therapeutic Notes), with some local 
applications may constitute sufficient treatment. 

In the case of chronic urticaria, it behooves the physician to 
investigate with care the general disturbances so as to remedy these. 
Thorough hygiene of the nervous system and a strict alimentary 
regimen, sometimes a closely prescribed diet, are imperative. 

Internal medication may be required, such as calcium salts, 
ferments or yeasts, ichthyol, salicylates, alkalis, mineral waters 
or intestinal irrigations. The subcutaneous injection of 0.5 mg. 
of adrenalin often attenuates the crises and repeated applications 
have cured a few cases. [Immediate relief is often obtained by 
the subcutaneous injection of 0.01 gm. of pilocarpin muriate.] 

The remarkable efficacy of serotherapeutic treatment in some 
cases of urticaria has attracted attention to the study of the differ- 
ent forms of this method, but its results are not constant. Some- 
times a rapid cure has been obtained by copious venesection followed 
by intravenous injection of physiological salt solution, by the 
injection of* serum from a healthy person, by autoserotherapy, by 
the injection of animal serum in very minute doses. The need of 
caution in the employment of these remedies cannot be overempha- 
sized, as they are liable to aggravate the trouble. The procedures 
designated to establish an anti-anaphylactic state have not yet been 
formulated. 

External measures, although constantly demanded by the patient 
for the relief of the pruritus, are of minor importance. Baths and 
douches, it is well to know, often aggravate the trouble; and 
similarly ointments. Soothing acid or alcoholic lotions are prefer- 
able and should be applied warm or cold, or rather lukewarm, with 
a decoction of slippery elm, lime, or chamomile, or with a solution 
of vinegar, lemon- juice, camphorated alcohol, carbolized glycerin, 
menthol, thymol, resorcin, etc., followed by abundant applications 



URTICARIA FACTITIA, OR DERMOGRAPHISM 49 

of neutral powders. The hygiene of the skin requires some atten- 
tion; the underclothing should be light, of fine smooth texture and 
must not rub or press on the skin. 

Whatever the cause of the urticaria, the treatment should not be 
schematic but should be specially adapted to the requirements 
of the case. 

GIANT URTICARIA. 

Under this name, or that of acute circumscribed edema of Quincke, 
an affection has been described which manifests itself by the sudden 
appearance of edematous infiltrations, usually fairly well outlined, 
firm, pinkish or porcelain-white in the center, with a rose-colored 
periphery. These infiltrations have the size of a hazelnut, walnut, 
or even an orange; their elevation may amount to several centi- 
meters; they are the seat of a sensation of tension, burning or 
itching. They may appear at any point of the integument or 
even of the mucous membranes, although the face and the region 
of the genital organs are the seats of predilection. 

The attack comes on suddenly, often during the night, without 
prodromata or with some malaise and a slight fever; a single eleva- 
tion, or a small number, appear and persist for a few hours, at most 
two days. The attacks may be periodically repeated or they may 
be separated by intervals of variable length. 

This affection persists for years, associated or not with common 
chronic urticaria; it finally disappears, sometimes to become 
replaced by other pathological manifestations. Its possible locali- 
zation in the upper respiratory passages represents the only danger- 
ous element. Also, according to the seat of the edema, the patient 
may be disfigured for a few hours. 

Etiology. — The etiology is the same as that of chronic urticaria. 
There exist intermediate cases between this and Quincke's edema. 

The paroxysms sometimes follow overeating, errors in diet, 
nervous overstrain or the action of cold. In the interval, the 
patient may enjoy excellent health. 

Treatment.- — The treatment follows that of ordinary urticaria. 
Simple calcium chloride, systematically administered, in courses, 
has repeatedly proved entirely successful in my experience. 

URTICARIA FACTITIA, OR DERMOGRAPHISM. 

It has been stated above that in most cases of urticaria, the 
eruption can be provoked at the time of the attacks by scratching 
or other cutaneous irritations. Dermographism is an altogether 
different phenomenon. In certain individuals, a mechanical irri- 
tation, especially forcible friction with a blunt point gives rise to 
4 



50 



URTICARIA 



a special cutaneous reflex, a non-pruritic urticarial elevation. A 
very brief stage of anemia with prominence of the hair follicles, 
is followed by the appearance of a bright pink line, which widens 
to 1 to 2 cm., the middle becoming raised in less than a minute in 
the form of a ridge. At the end of five minutes this ridge may 
attain a height of 3 to 1 mm. and a breadth of 1 cm.; the phenome- 
non usually lasts from fifteen to twenty minutes or sometimes 
several hours. Although electrical stimulation or other irritations 
may also cause its appearance, a mechanical action is most effec- 
tive. Friction over the affected region, after the complete sub- 
sidence of the phenomenon, may cause the reappearance of the 
writing or designs which had been traced on the skin. 




lographism 



Dermographism is observed especially on the trunk and on the 
first segments of the limbs. It is rare in the face, but is said to 
have occurred on the buccal mucosa. 

Dermographism is one of the stigmata of the neurotic constitu- 
tion. It is met with in hysterical individuals, in epilepsy, in 20 per 
cent, of the insane, especially among idiots and constantly in 
catatonia ; furthermore, in the victims of lead poisoning and chronic 
alcoholism, especially in consumers of aromatic liquors. In the 
spring, during the menstrual periods and after emotions or fatigue, 
dermographism is the most marked. It is noteworthy that it 



TREATMENT 51 

does not often occur in association with common urticaria. Its 
name of pseudo-urticaria is derived from the absolute objective 
identity between the dermographic elevation and the urticarial 
wheal. The suggestion has been made that the mysterious aspect 
of this phenomenon may have led to its being used in former days 
in the tricks of sorcerers. At the present day, malingerers have 
utilized it for the simulation of some other eruption. 

Treatment. — The treatment consists in attention to hygiene, if 
necessary, and care of the general condition. 



CHAPTER III. 
PURPURA. 

The name purpura is applied to an eruption of spontaneous 
hemorrhagic spots. The spots of purpura are of a bright or bluish 
red and do not disappear under pressure of the finger; they are 
usually of rounded shape, flat or slightlv elevated, of variable 
extent, more or less numerous, but always multiple. 

Petechia is the term in use for the description of small punctiform 
or lenticular lesions; they sometimes surround the pilo-sebaceous 
orifices. Ecchymoses are more extensive and irregular; they vary 
in size from that of a coin to that of the hand, or more. A less 
common term, vibices, designates more elongated or striated 
purpuric spots. 

After a few days or weeks, depending on their size, these hemor- 
rhagic spots fade away, after having passed through the same 
shades, purplish, brownish, greenish and yellowish, as the traumatic 
ecchymoses. 

Petechia 1 are highly characteristic, being necessarily spontaneous; 
ecchymoses may have been produced by a forgotten or wilfully 
denied traumatism, sometimes very insignificant in the victims of 
hemophilia. 

Purpuric spots must not be confused with vascular nevi, which 
are of indefinite duration; nor with the spots of erythema, which 
fade away under pressure of the finger. 

The combination of erythema with different varieties with pur- 
pura, either in the same spot as the hemorrhages or coincidently in 
the same region, is not unusual. The purpuric spots may also be 
urticarial at the onset (purpura urticans) or become complicated 
by urticaria. 

We must therefore admit an obvious relationship, transition- 
forms and various combinations, between purpura, erythema and 
urticaria (such as erythema nodosum contusiforme, urticaria hemor- 
rhagica, etc.). 

The term purpura should not be applied to occasional hemor- 
rhagic eruptions, such as occur in smallpox, herpes zoster, eczema, 
pemphigus and the pyodermatitides. Such conditions are properly 
described as hemorrhagic variola, etc. 

The eruption of purpura comes on in sudden or prolonged attacks, 
which arc frequently successive. The attack may be preceded by 



CLINICAL FORMS 53 

inflammatory local edema, sometimes lymphangitic, of short dura- 
tion and accompanied by heat or pruritus, or it may occur without 
the patient's knowledge. The affected region appears irregularly 
dotted with lesions, all of the same size or of different sizes, of 
the same age or at different stages of their development. 

The distribution of purpura is often more or less symmetrical; 
the lower limbs are most commonly and sometimes alone affected, 
or sometimes all the extremities are involved. The eruption may 
occupy any location and may even invade the mucous membranes, 
where it is apt to assume the form of blood blisters which rupture 
and give rise to hemorrhage. 

In some cases of purpura, it is possible to produce a hemorrhagic 
spot through moderate pressure on the skin with a blunt point 
(provoked purpura), or an eruption of petechia? through the tempo- 
rary constriction of a segment of the limb (tourniquet purpura) . 

Clinical Forms. — The eruption of purpura is sometimes merely 
a commonplace symptom of several pathological conditions; these 
cases are described as secondary purpuras. Again, it may form 
part of one of the syndromes designated as primary purpuras, 
representing their most salient feature. 

As a matter of fact, purpura occurs under very different condi- 
tions; occasionally ia the midst of health and without an appreciable 
determining cause; or as a sequel of overstrain, or after intoxica- 
tions; or in the course of definite infectious diseases or cachexias. 
It may furthermore be associated with a train of general phenomena, 
among which rheumatoid pains, gastro-intestinal disturbances, 
fever, general malaise, etc., are especially common. 

On the one hand, the purpuric eruptions may occur without 
hemorrhage from the mucosa?, constituting purpura simplex. On 
the other hand, it may be accompanied by very profuse epistaxis, 
bleeding from the buccal mucous membranes, especially the gums, 
metrorrhagia, melena, hematuria or visceral hemorrhages, consti- 
tuting purpura hemorrhagica. 

This division, for which we are indebted to Willan, can only be 
maintained from the descriptive point of view, for it does not 
correspond to a difference in etiology; a simple purpura may at 
any time become transformed into purpura hemorrhagica. It is 
not even in harmony with the prognosis, purpura hemorrhagica 
being sometimes benign and at other times grave. 

It seems more rational to base the establishment of the clinical 
types on the question of whether the purpura is a simple symptom 
or whether it constitutes a syndrome. 

Great differences of opinion on this point exist among authors. 
The following forms are generally admitted, although under different 
designations : 



:>i PURPl RA 



SECONDARY PURPURAS. 

The secondary purpuras arc those which appear as an ordinary 
symptom or epiphenomenon in the course of a large number of 
pathological conditions. They possess an indicative value, but are 
of little importance in themselves. 

Four classes of these purpuras are recognized: 

1. Mechanical "purpuras, which occur on the limbs under the 
influence of prolonged constriction, or at any point of the body in 
the course of asystole [in a disturbance of cardiac compensation] 
or of lits of whooping-cough or attacks of epilepsy. 

2. Toxic purpuras, which may be provoked by certain medicinal 
agents such as phosphorus, potassium iodide, mercury, arsenic, 
antipyrin, chloral, salicylates, quinin, belladonna,, ergot, copaiva, 
etc., as well as by injections of antitoxic sera, bites of venomous 
serpents, etc. 

3. Secondary purpura of the acute infection* diseases, such as 
angina, diphtheria, scarlet fever, gonorrhea, typhoid, typhus, 
miliary tuberculosis, malaria, etc. 

1. Cachectic purpuras, observed at advanced stages of serious 
diseases, cancer, tuberculosis, Bright's disease, hepatic cirrhosis, 
icterus gravis, pernicious anemia, the leukemias, etc. The erup- 
tion usually comes on insidiously, without inflammatory phenomena, 
sometimes with edema and occupies chiefly the lower extremities. 

The group of cachectic purpuras is really most heterogeneous 
and many cases are probably referable to an infection, auto-intoxi- 
cation, nervous lesions or anomalies of the blood. 

Purpura senilis- of Bateman has sometimes been grouped under 
the same heading. r l nis designation is applied to purpuric spots 
which occur incessantly, for years, without general disturbances, 
in aged individuals; located predominantly on the forearms. Unna 
and Tasini have shown that these cutaneous hemorrhages are related 
to senile degeneration of the skin. 

PRIMARY PURPURAS. 

The primary purpuras are those in which the petechia' and 
ecchymoses, with or without hemorrhages of the mucous mem- 
branes, represent the exclusive or principal phenomenon. Several 
types are recognized : 

1. Rheumatoid purpura is the most common; it is identical with 
Schoenlein's peliosis rheumatica and the myelopathic purpura of 
Paisans. 

It occurs in both sexes but more frequently in youthful or adult 
males and is supposed to follow on exposure to damp, cold, fatigue, 



PRIMARY PURPURAS 55 

overstrain or emotional disturbances. The onset is often marked 
either by a sensation of fatigue or articular pains in the lower 
limbs, or by a more or less extensive transitory edema in the same 
regions, or finally by gastro-intestinal disturbances. Fever is 
variable, not high and may be absent. 

The rheumatoid pains are arthralgic, associated or not with 
articular swelling; they affect the knees and ankles especially, but 
may extend to the joints of the upper extremities. 

Sometimes the pain is muscular or neuralgic. The distinction 
between these rheumatoid naiiis and those of acute rheumatism has 
been emphasized by Besnier. 

The gastro-intestinal disturbances consist in repeated vomiting 
with gastralgia, in intestinal colics, often severe, simulating the pains 
of peritonitis, or accompanied by diarrheal crises, melena, or dys- 
enteriform evacuation. These various manifestations precede or 
accompany the eruption and are temporary, but may sometimes 
recur in the course of the disease. Various complications have been 
noted on the part of the serous membranes and the viscera. 

The eruption consists of petechia, more or less mixed with small 
ecchymoses; it affects especially the lower limbs symmetrically 
(Fig. 6), but may become generalized, beginning with the upper 
limbs. Not infrequently, it is polymorphous, mixed with papular, 
nodular, or urticarial erythema. The name of purpura exanthe- 
matica is used by Laget for this eruptive complex. 

The attacks recur at very irregular intervals. They are sometimes 
so obviously aroused by posture or walking as to justify the expres- 
sion of "orthostatic purpura." Periodical attacks coinciding with 
the menses have also been observed. 

The majority are cases of purpura simplex. Hemorrhages are 
rare, but may supervene in the course of evolution, aggravating 
the clinical picture. 

The duration of the disease is ordinarily a few weeks; but some 
cases are prolonged for several months. Recurrences may take 
place at irregular intervals. 

The severity of the systemic symptoms varies within extreme 
limits; sometimes they have to be looked for, or, on the contrary, 
they may have the appearance of a grave infection. 

Sporadic scurvy, only rare cases of which are now met with, 
differs from rheumatoid purpura by its etiology, which involves 
confinement and deprivation of fresh foods, as well as by the swollen 
condition of the gums and the well-marked anemia and asthenia. 
These cases, however, may be interpreted as rheumatoid purpura 
developing in a prepared soil. 

In infantile scuroy or Barlow's disease, the ecchymosis and hemor- 
rhages of the mucous membranes are far from constituting the most 



56 



Pl'RPT 'HA 



important feature of the clinical picture, in which painful pseudo- 
paralysis [due to involvement of the joints] predominates. 

Although apparently primary, the cases of chronic purpura, 
reported especially by Hayem and his school, as well as by Millard 
and others, are probably of autotoxic origin or connected with a 
more or less latenl infection, such as tuberculosis. The continuous 
or intermittent cutaneous and hemorrhagic manifestations mav be 




Purpura rheumatoides 



prolonged for ten or twenty years, the prognosis being nevertheless 
regarded as relatively favorable. This form must not be confused 
with hemophilia, which is congenital and hereditary and in which 
the coagulability of the blood is always markedly diminished. 

I nderthe name of purpura annularis telangiectoides, a well-defined 
clinical type was described by Majocchi, in 1895, and has since been 
studied by several authors. It consists of dull red spots, symmetri- 
cally distributed on the lower limbs especially, at first telangiectatic, 



PRIMARY PURPURAS 57 

then hemorrhagic and becoming ring-shaped through gradual cen- 
trifugal extension. Pasini attributes these spots to endophlebitis 
of the small, deep veins of the skin. The etiology of this dermatosis 
is entirely unknown. 

2. Primary infectious purpuras are those in which the general 
symptoms indicate an infection of the type of septicemia. Besides 
relatively attenuated forms, which form a connecting link with 
rheumatoid purpura, there occur very grave forms, such as the 
angiohematic typhus of Landouzy and Gomot, and the purpura 
fulminans of Henoch. 

Such cases may begin with a severe initial chill, vomiting, a tem- 
perature of 40° [104°], typhoid stupor, delirium, coma, dry tongue, 
albuminuria and sometimes .icterus, together with scattered petechia 
and ecchymoses and hemorrhages from various avenues. The pur- 
puric lesions may become gangrenous; cellulitis, purulent arthritis, 
etc., may occur. Several of these cases have recently been traced 
to infection by the meningococcus, the presence of which in the blood 
and in the spots has been demonstrated by A. Netter and Salanier. 
Death may follow in two or three days in the acute variety; or in 
one or two weeks, in the typhoid variety. 

3. Abrupt apyretic purpura hemorrhagica, or morbus maculosus — 
two typical instances of which were published by WerlhofT — is a 
rare form. According to a generally accepted standard, its behavior 
is as follows: 

In the midst of health, sometimes after an emotion or slight 
traumatism, often without prodromata or malaise, without fever, 
a slight nasal or gingival hemorrhage makes its appearance. On 
the next day, petechia are noted on the lower limbs, then larger 
scattered ecchymoses together with hemorrhages from various 
mucous membranes. After ten to fifteen days, recovery sets in 
without complications. Neither infection nor intoxication, nor a 
grave lesion of the blood have been demonstrated in the course of 
the disease. 

It appears more and more probable that a considerable number 
of the clinical forms of purpura discussed above, notably the primary 
purpuras, the secondary purpuras following infectious diseases 
and even some of the so-called cachectic purpuras, do not constitute 
distinct diseases, but merely degrees or variations of the same 
morbid process. Interpreted in this manner purpura, simple or 
hemorrhagic, would be merely the consequence of various acute or 
chronic infections, causing alterations in the composition of the 
blood and vascular or visceral lesions which in turn are responsible 
for the different aspects of the syndrome. 



58 PURPURA 

Pathogenesis. Purpura is observed in both sexes, at any age, 
under a great variety of conditions as referred to above. 

Pathological Anatomy. — Pathological anatomy teaches that the 
purpuric spots always contain an effusion of blood, with its white 
corpuscles; situated at a variable level in the meshes of the derma 
or hypoderm up to the papillae, where it undergoes the usual changes 
of extravasated blood. Sack has shown that vascular rupture most 
frequently occurs in the small veins of the subdermal plexus. The 
vascular walls, although various changes and degenerations have 
been reported, are nearly always in a remarkably intact condition. 

In the absence of local lesions to account for the hemorrhages, 
different general conditions have been invoked, which, however, 
do not exclude one another. 

In the circulating blood, the number of red cells remains normal, 
except in case of profuse hemorrhages, or pernicious anemia; the 
number of white corpuscles is rarely changed (leukemias) ; the blood 
platelets — according to Denys, Hayem, Bensaude and others, con- 
firmed by W. Duke — may become very scanty, or even entirely 
disappear (L. Le Sourd and Pagniez). As to humoral lesions, a 
retarded or normal coagulation of the blood, a non-contracting or 
imperfectly contractile and friable clot and an increased red blood 
cell resistance has been noted. The "bleeding time" (W. Duke) 
may be greatly increased. However, these various phenomena are 
inconstant; their importance, mutual relations and pathogenic 
significance are still under investigation. 

Viscera] lesions are common. Those of the liver and kidney may 
be charged with having prevented the destruction or the elimination 
of certain toxins; on the other hand, the role of the hepatic function 
in the coagulation of the blood is well known. Changes in the intes- 
tinal tract arc frequently found in the purpuras, as shown by clinical 
observation and autopsies; 1 believe that the intestinal tract is often 
the starting-point of the infection or intoxication to which the 
purpura is due, perhaps through intermediation of the liver which 
is damaged in transit. A form of abdominal purpura has even been 
described (Henoch). A pathological condition of the suprarenal 
glands and hi Ivessel glands has sometimes been held responsible. 

The role of the nervous system is shown by a large number of 
facts. The rheumatoid pains characteristic of certain primary 
purpuras have been referred to above. Petechial eruptions have 
been observed in the course of myelopathies and neuritis. Straus 
has noted their coincidence with the fulminating or lightning pains 
of tabes. There are cases of purpura involving only one-half of the 
body, or even in exceptional cases assuming a metameric or radicular 
distribution, proving at any rate a localizing influence of the nervous 
system. Spinal puncture sometimes, but not invariably, reveals a 



PRIMARY PURPURAS 59 

lymphocytosis of the cerebrospinal fluid. Finally, Grenet has suc- 
ceeded in the experimental production of purpura in rabbits, by 
first damaging the liver and then injecting toxins into the spinal 
cord. 

The possible effect of intoxications is illustrated by the existence 
of the toxic purpuras, which have been mentioned. A probable 
influence of auto-intoxications and perhaps of microbic toxins may 
be inferred. 

Infection, as I have intimated, is probably responsible for all the 
non-toxic forms of purpura. Originally asserted by Hayem, this 
fact has been established by clinical observation and laboratory 
research in a group of cases and is very probable for the remainder, 
including the so-called neuropathic, dyscratic, or cachectic purpuras. 
Moreover, the literature contains a very considerable number of 
cases where the staphylococcus, streptococcus, pneumococcus, pyo- 
cyaneus, meningococcus, etc., have been demonstrated either in 
the purpuric spots or in the circulating blood. These facts tend to 
show that a variety of infections may manifest themselves in the 
clinical picture of purpura. 

It is possible, but by no means an established fact, that there 
exists a specific microbe, more apt than others to produce the patho- 
logical picture of infectious purpura. This would serve to explain 
the cases of epidemic and contagious purpuirc fever, mentioned by 
some authors, the occurrence of which, however, is somewhat 
doubtful. 

Treatment.— Any case of purpura, even when its onset is appar- 
ently most harmless, must be carefully watched, as it is impossible 
to foretell when and how it will end. These patients should accord- 
ingly be put at rest, under good hygienic conditions, on strict diet 
and in the open air if possible. For the control of the hemorrhages, 
the old medication with acids, ratanhia, hamamelis, ergotin, iron 
perchloride, is now abandoned, experience having shown them to be 
utterly useless. They have been replaced by modern agents, such 
as gelatin, calcium chloride, injections of peptones and blood-sera, 
hepatic and suprarenal extracts, adrenalin, pituitrin, etc. 

The results obtained in the treatment of hemophilia and hemo- 
globinuria have led to experimentation with methods acting on the 
equilibrium of the blood, modifying its coagulability and producing 
what Widal has described as the "hemoclasic crisis." Injections 
of horse-serum, in large amounts, or in moderate or minute repeated 
doses, as well as autoserotherapy, have their advocates. [A careful 
search must be made for occult sources of infection with special 
attention to the teeth and the tonsils.] These methods, which do not 
exclude adjuvant medication, especially with calcium salts, have 
yielded very encouraging results, but their indications have by no 
means been definitely formulated. 



CHAPTER IV. 
ECZEMA. 

The eruption known as eczema is not characterized by a single 
eruptive element, but by a series of elementary lesions which suc- 
ceed each other, combine or coexist in neighboring localities. These 
lesions are the result of an inflammatory process, affecting the epi- 
dermis and cutis ; an epidermo-dermatitis, comprising several stages 
which are of equal importance. 

Clinically, these stages are manifested under the following aspects: 
erythema, resiculation, exudation, crust formation, lichenization and 
desquamation. 

Histologically, the lesions consist, in the epidermis, of spongiosis, 
acanthosis and parakeratosis; in the cutis, of congestion, edema and 
moderately abundant cellular infiltration. 

This definition must be supplemented by mention of the three 
characteristic features of the eruption: its usual arrangement in spots, 
patches, or surfaces with irregular outlines (insular, geographical or 
archipelagous) ; its development in crops or relays, with a tendency 
to peripheral extension and often to a chronic state with fresh 
exacerbations and its more or less pruritic character. 

Defined in this way, the eczematous process is one of the most 
easily recognized. It must be appreciated, however, that this proc- 
ess is not limited to a single and specific dermatosis, but on the 
contrary represents a relatively common mode of reaction of the 
skin toward a series of mechanical, physical, parasitical and microbic 
i nit ants. This reaction must be considered in all respects as 
inflammatory. 

Eczema, Eczematization, Eczematosis. —The subject of eczema 
lias become extremely complicated and much confusion has been 
caused by the application of the term eczema for some time to 
absolutely different conceptions. Eczema was interpreted by Hebra 
and the Vienna school of dermatologists, as a very common poly- 
morphous affection, which may at any time be artificially produced 
in any person. According to the French school, on the other hand, 
eczema was a rare disease, especially in the clinical material of 
hospitals, incapable of being artificially produced, since it implies 
the existence of a general predisposition — altered tissue-juices — 
a diathesis. Hence, two entirely distinct groups of facts had to be 
dealt with. Besnier, in 1S92, was perhaps the first to elucidate 



ECZEMA, ECZEMATIZATION, ECZEMATOSIS 61 

the controversy by creating the word eczematization to designate the 
eczema of Hebra-Kaposi, which is not a disease but an eczematoid 
artificial dermatitis. The eczema of French writers, on the contrary, 
is a true disease, which although having multiple causes is related to 
a peculiar condition of the individual; this disease is chronic and 
recurrent. The eruptive manifestation of eczematous disease is 
identical with that of eczematous lesions, or eczematization. 

The question would thus seem to have become quite clear, but on 
closer examination considerable difficulties of interpretation are 
encountered. If several persons be subjected to the same external 
irritant, for example, rubbing with spirits of turpentine or tincture 
of arnica, some will experience at the injured point a transitory 
erythema or a dermatitis in the form of eczematization with a 
marked tendency to subsidence; in others, this dermatitis will be 
extensive and may even become generalized, then healing more or 
less rapidly; and finally, in others, its duration will be prolonged, 
recurrences supervening on slight causes or even in the absence of 
an appreciable cause and this abnormal condition may occasionally 
persist throughout life. 

Several suggestions have been made in explanation of these 
differences in the evolution of the lesions. It has been claimed that 
an eczematization produced by contact with an irritant, no matter 
what its evolution and duration, is and remains an artificial eczema- 
toid dermatitis, there being only an objective and apparent identity 
between it and the disease eczema dependent on a diathesis. This 
interpretation would necessarily lead to grouping absolutely similar 
clinical pictures under different headings and to basing the diagnosis 
on the patient's statements or on an estimate of the irritative proper- 
ties of the supposedly provoking causes. 

It has also been stated that an ordinary eczematoid dermatitis 
may become transformed into a specific dermatitis; but this can 
hardly be admitted, as it is not known wherein the specificity of the 
disease eczema lies. 

Obviously, on the contrary, the persons of the first group in the 
above-mentioned example, were in a state of physiological integrity, 
investing them with relative immunity toward the injurious agent, 
whereas, pathological conditions creating a morbid tendency existed 
in the others. Those who were affected in the most severe and per- 
sistent manner were eczematous subjects in whom a local irritation 
sufficed to bring out a hitherto latent disease. Although this is 
entirely plausible, it must be added that, keeping in mind the very 
variable evolution of eczematous dermatitis of artificial origin, one 
is forced to admit an entire scale of subnormal and abnormal states, 
creating a more or less marked predisposition for the appearance, 
persistence and recurrence of the eczematous eruption. 



62 ECZEMA 

Thus all distinct boundaries or fundamental differences between 
eczematization or artificial eczematoid dermatitis with a rapid 

tendency to spontaneous cure and true eczema, a chronic recurrent 
disease, are obliterated. It is now merely a question of degree and 
there remains no valid reason for withholding the name of eczema 
from any eczematization, whether of artificial or of apparently 
spontaneous origin. 

The term eczema will therefore be applied in this book to all 
eruptions corresponding to the definition at the beginning of this 
chapter. This name will be supplemented by qualifying adjectives, 
referring to the momentary objective appearance (vesicular, exuda- 
tive, crusted eczema, etc.), or to the evolution (acute, chronic, 
recurrent eczema), or to the apparent etiology (artificial, occupa- 
tional, microbic eczema, etc.). 

I propose the term eczematosis for the chronic pathological con- 
dition described by other authors as constitutional eczema, eczema- 
disease or true eczema. 

I shall speak of secondary eczematization, or of an eczematized 
dermatosis, when a dermo-epidermatitis of eczematous type becomes 
superadded to the lesions of a preexisting dermatosis (example: 
eczematized prurigo, eczematized psoriasis, etc.). 

Finally, as will be seen in the next chapter, I call eczematides the 
dry eczemas, the eczema seborrhoeicum or seborrheids of other 
authors. 

Pathological Anatomy. — Eczema being an inflammatory patho- 
logical process clinically manifested by very variable objective 
appearances, the nature of their process must be studied in detail 
before describing the manifestations. 

1 . The chief lesion of eczema is an edema of the Malpighian body; 
the serous fluid infiltrates between the epidermic cells, stretching 
their connecting filaments, so that the rete assumes an appearance 
which is very properly denominated as a spongioid state, by I Tina, 
and as spongiosis, by Besnier. 

2. When in the spongioid state, the fluid has sufficient pressure 
to rupture the connecting filaments of the Malpighian cells, it collects 
in vesicles, cavities filled with a transparent fibrinous plasma, con- 
taining a few wandering cells and bounded by epidermic cells which 
have been pushed aside and sometimes compressed. These vesicles, 
which at first are very small, originate in the deep layer of the epi- 
dermis; they increase in size an 1 become confluent with neighboring 
vesicles until they are visible to the naked eye and protrude under 
the horny layer; ultimately vesicles form at all levels in the rete; 
the oldest arc pushed up toward the surface by the outward growth 
of the epidermis and new ones are often formed beneath them. 



ECZEMA, ECZEMATIZATION, ECZEMATOSIS 



G: : i 



The vesiculation of eczema is therefore interstitial and dependent 
on the spongiosis, therein differing from the vesiculation of zona, 
varicella, etc. 

The ultimate fate of eczema- vesicles is variable; they terminate 
by desiccation or rupture, or become secondarily infected. 
_ 3. The first contingency, desiccation without oozing or suppura- 
tion, may eventuate, no matter what the size of the vesicles, in 
regions where the epidermis is resistant. It gives rise to tiny 
crusts or larger crusts, composed in variable proportions of dried 
serum, the remains of parakeratotic cells and collections of microbes. 
The epidermis reforms below and the crusts are shed. Desiccation 
of the foci of spongiosis is the rule in certain forms having a rather 
peculiar clinical appearance and course, so that they have been 
separated from the group of moist eczemas under the name of dry 
eczemas or seborrheal eczemas. They will be described further on 
under the name of eczematides (p. 90). 




Fig. 7. — Histology of eczema. X 45. A, infected vesicle; B, crust; C, parakera- 
tosis; D, acanthosis; E, papillary edema; F, vesicle; G, spongiosis; H, perivascular 
infiltration. 



4. When the vesicles have ruptured spontaneously or under the 
influence of scratching or rubbing, their contents are poured out 
externally and there is weeping or oozing. In weeping eczema, 
the escape of serous fluid is often prolonged, without production of 
new vesicles, because the fluid of the spongiosis which is incessantly 
reproduced, finds a way of escape through the open cavity of the 
ruptured vesicles; these constitute the eczematous pores. The process 
of keratinization being altered, as will be shown further on, a rapid 
cicatrization of these orifices cannot occur. 

5. The vesicles of eczema may be microbic from the start, or they 
may be originally sterile. In the latter case, they are easily infected 
by pyogenic microbes, which find them an excellent culture medium 



64 ECZEMA 

to which they attract an abundance of polynuclear leukocytes. This 
is known as impetiginization (p. 162). 

In these infected or impetiginous eczemas, the fluid is turbid or 
purulent and dries in thick mclicerous crusts, under which the 
epidermis remains deeply eroded; moreover, the increased viru- 
lence of the microbes, once they begin to grow, leads to a peripheral 
extension of the lesions and their remote propagation in the form 
of microbic eczema or of true impetigo. 

(>. Coincidently with the spongiosis, the Malpighian edema gives 
rise to the change of keratinization known as parakeratosis; this is 
characterized by the disappearance of the stratum granulosum 
and preservation of the nuclei in the cells of the homy layer, which 
contains less fat than in the normal state. In a general way, the 
parakeratosis controls desquamation and it accordingly predomi- 
nates in the squamous, lamellar, psoriatiform , "craquele," u corne," 
hyperkeratotic eczemas, etc. 

7. The spongiosis and the vesiculation, or rather more probably the 
persistence of the causes which have started and maintained them, 
lead at the end of a certain time to an abnormal multiplication of 
the Malpighian cells, hence thickening of the rete; this process is 
called acanthosis. The mterpapillary pegs are enlarged and the 
papillae are proportionately elongated and narrowed, although fre- 
quently edematous. This thickening of the epidermis and of the 
papillary body results in the appearance of the so-called lichenoid 
eczema. The papillary body in such cases is usually the seat of 
more or less abundant infiltration. 

8. The fluid or plasma of this intra-epidermic edema, which is 
seen to govern practically the entire eczematous process, is obviously 
derived from the cutis, where it is exuded from the congested and 
dilated bloodvessels of the papillary body. 

The epidermic lesions described above are accordingly preceded 
by dermic lesions, consisting of hyperemia and edema of the papil- 
lary body, with moderate diapedesis of white corpuscles mixed 
with a few red cells, which accumulate as a perivascular infiltration. 
These lesions manifest themselves clinically by redness and swelling, 
the symptoms being sometimes slightly marked, but in other cases 
constituting the most obvious phenomenon, for example in acute 
eczema of the face and in eczema rvbrum. 

Of the various elementary anatomical lesions the most essential 
are: spongiosis, parakeratosis and acanthosis; all others depend on 
them. They may become combined or associated, or succeed each 
other in such a way as to give rise to the multiple aspects which 
eczema may assume. It must be kept in mind that the qualifying 
terms vesicular, exudative, squamous, etc., do not designate species 



ECZEMA, ECZEMATIZATION, ECZEMATOSIS 65 

or even varieties of a distinct type, but only accidental, temporary, 
or more or less persistent phases. 

General Etiology. — Considered as a whole, eczema is the most 
common of all cutaneous affections. Its different varieties and 
localizations make up nearly one-third of dermatological practice. 
[In the statistical reports of the American Dermatological Associa- 
tion, covering about three-quarters of a million dermatoses, the 
eczemas, including eczematides, comprise about 20 per cent, of 
the total.] It is observed at all ages; during early childhood 
{infantile eczema), then in the period of active life (occupational 
eczemas), finally in the stage of decline of organic resistance (senile 
eczema). The two sexes are equally susceptible and no social class 
is immune. 

Its causes may be divided into external, determining, or occasional 
and internal or predisposing. 

External Causes. — These are innumerable. Nearly all local irri- 
tants of any kind, whose moderate influence excites erythema, are 
capable of causing eczema when their action is augmented. It 
must be noted, however, that these agents are eczematogenous 
to a variable degree, some of them requiring a more decided pecu- 
liarity or cooperation of the organic soil. Predisposition therefore 
has a bearing not only upon the extent and duration of the reaction, 
but upon its character also. 

Among the local factors of eczema must be mentioned mechanical 
agents, such as scratching; physical agents, such as a bright light 
(Wilson's eczema solare), heat (eczema caloricum); and countless 
chemical irritants (arnica, turpentine, phenol, etc.). The majority 
of these injurious factors will be considered in the chapter on the 
artificial dermatoses (XXIII). Only a few causes of particular 
interest will be discussed in what follows: 

Traumatic Eczema from Scratching. — Eczema causes itching; the 
scratching of the eruption, often evidently aggravates it and in some 
cases may be responsible for its extension and dissemination. The 
question arises under these circumstances whether the scratching 
served to transport the irritative agent or the microbes which had 
invaded the primary focus, or if the skin was directly eczematog- 
enous as a result of individual prediposition. This dissemination 
was regarded by Kaposi as the effect of an eruptive reflex. In 
another group of cases, scratching is primary as compared to the 
eruption; this is the case, for example, in pruritus and prurigo (pp. 
481 and 488), in scabies and pediculosis, also I believe in ichthy- 
osis, in the circulatory disturbances of the lower limbs, etc. There 
exists accordingly a true traumatic eczema. 

Parasitic Eczemas. — Aside from pruritus, or under conditions 
where scratching is impossible, parasitic affections may give rise to 
5 



66 ECZEMA 

genuine eczematization. The eczemas of scabies and pediculosis 
may therefore be referable either to scratching or to the virus of 
the parasites. 

In trichophytosis of hairless parts, the type known as herpes 
circinaius where pruritus may be almost entirely absent, vesicles 
due to spongiosis arc observed, followed by parakeratotic desqua- 
mation. It seems to me justifiable to consider these as eczematous 
and to attribute them directly to the fungus in the majority of the 
cases. 

Microbic Eczemas. — The question as to the part played by 
microbes in eczema has been raised only relatively recently. 
Twenty-five years ago nobody suspected that it would ever arise; 
and certain modern writers have probably exaggerated its impor- 
tance. 

Unna regards eczema as a microbic dermatosis; the non-microbic 
affections which simulate it are eczematiform eruptions, for the 
most part artificial dermatitides, but not true eczema. The 
pathogenic parasite of eczema in his opinion is the morococcus, or 
the morococcic group; this is the name applied by him to the cocci 
which are found in mulberry-like collections under the roof of the 
vesicles. Later studies have identified these morococci with certain 
staphylococci (p. 536). 

As a matter of fact, it has been established by careful investi- 
gations- among which those of Veillon, Sabouraud, Halle and 
Civatte are specially mentioned because I personally assisted in 
their work — that the vesicles of dermatoses which must be regarded 
in all respects as eczemas, are primarily amicrobie, in the case of 
artificial eczemas as well as of constitutional eczemas. These 
vesicles may become infected secondarily by the ordinary microbes 
of the skin. 

On the other hand, these microbes are undoubtedly capable of 
exciting the reaction of eczematization when they invade the 
epidermis through the agency of mechanical, physical or chemical 
traumatization, or of macerating lesions of the protective horny 
layers; or of an abnormal structure of this layer and its adnexa, as 
occurs in ichthyosis and especially in kerosis (XI); or of local or 
regional circulatory disturbances, as in varicose eczema; and finally, 
even on the normal skin, when they have acquired an increased viru- 
lence through culture, in impetigo or any kind of wound, fissure, 
fistula, etc. 

In eczema of war /rounds, described by me as paratraumatic 
eczema (p. ".">), countless instances of which have recently been met 
with, these various conditions were generally associated; the lesion 
of the epidermis produced by iodin, peroxide water or other anti- 
septics, maceration through the dressings, local circulatory dis- 



ECZEMA, ECZEMATIZATION, ECZEMATOSIS 67 

turbances, contamination of the surface by the pus of the wound or 
fistula, combining to produce a genuine type of microbic eczema, 
more or less impetiginous. 

The facts adduced in favor of the general parasitic theory of 
eczema (Unna, Leredde) are capable of other interpretations. 
This is true for the auto-inoculation of eczema by scratching, etc.; 
its recrudescence from imperfectly extinct foci; the peripheral 
extension of eczematous patches; the identity of eczematous pro- 
cesses irrespective of the apparent causative agent; and the some- 
times easy curability by germicidal local applications. But these 
facts nevertheless constitute a set of impressive arguments, to which 
may be added a few observations, due to Unna, of positive inocu- 
lation of microbic cultures derived from eczema, which produced 
an eczematiform lesion in healthy inoculated subjects. 

Briefly, there exists an assembly of clinical data and laboratory 
findings, which prove the existence of an eczema of microbic origin 
and character. It is certain that various microbic species, especi- 
ally belonging to the staphylococcic group, may be eczematogenous. 
Perhaps there exists a still unknown microbe which more than 
others possesses this property. At the present writing, however, 
it is not possible to state that definite species of microbes corre- 
spond to the different forms and types of eczema. 

We are especially ignorant of the degree to which infection is 
responsible for eczema (for example in the artificial dermatitides, 
in eczema from scratching, in parasitic eczema, in the dissemina- 
tion of eczema), for up to the present time the clinician can no 
more recognize in a given case whether the eczema is microbic or 
not, than the bacteriologist can determine whether the detected 
microbe is primary or of secondary implantation. 

Internal Causes. — The general pathological conditions usually 
met with in cases of eczema, and which may be suspected of being 
internal or predisposing causes of this dermatosis, are the following : 
Heredity is often invoked and is said to be either direct, when the 
patient's parents were likewise eczematous, or indirect, when they 
suffered from obesity, diabetes, gout, rheumatism, lithiasis, asthma 
or migraine — briefly, from one or more of the multiple manifesta- 
tions of the nutritional disturbance known [in France] as arthritism. 
In other cases, the parents were inebriates, or exposed to various 
intoxications, neurotic, overworked, etc. 

The hygienic antecedents of the patient himself are sometimes 
distinctly bad, whether in regard to the abuse of stimulants, alcohol, 
coffee, tea, tobacco, etc., or to an excessive nitrogenous diet, over- 
eating, or food of an inferior quality, or to nervous strain in all its 
forms. 

Still more frequently, auto-intoxications are responsible, due to 



fiS ECZEMA 

gastric or intestinal dyspepsia, chronic enteritis, constipation, etc. 
I have often traced the trouble to a bad condition of the teeth, which 
at the same time causes intoxication by the putrefactive products of 
dental caries and pyorrhea alveolaris, and favors abnormal gastro- 
intestinal fermentation through incomplete mastication and insali- 
vation of the food. Sometimes, an insufficiency of the emunctories 
is properly held responsible, such as renal, hepatic or intestinal 
insufficiency, or a deficient function of the organs of internal secre- 
tion. Whatever may be the pathogenic mechanism, the relation 
between the dermatosis and these functional anomalies is entirely 
admisssible. Urinary examinations unfortunately yield no con- 
cordant results, rendering futile the hope of a coming " urinary 
formula of eczema." 

Nutritional disturbances, the hereditary influence of which has 
been referred to, are naturally still more injurious when affecting 
the patient himself. Sometimes, as the patient is sure to empha- 
size, an indisputable alternation or substitution is noted between 
the attacks of eczema and certain symptoms such as asthma, neu- 
ralgias, migraines, bronchial catarrhs, or digestive disturbances. 
An obstinate progressive eczema frequently precedes by several 
months or years, and so to say intimates, the manifestation of a 
latent visceral cancer. Diabetic patients are evidently predisposed 
to eczema which not uncommonly begins in the genital regions. 

The part played by nervous disturbances is equally apparent. 
A predisposition to eczema is created, not by central or peripheral 
nervous lesions, but rather by neurasthenia, overstrain, emotions, 
moral shock, grief, etc. We do not know if the nervous system 
acts through a vasomotor or trophic disturbance, which would 
already be the first stage of the eczematous process; or if it acts 
merely by lowering the resistance of the skin. At any rate, it 
seems to be a, loss of nervous balance which brings about the exces- 
sive irritability of the eczematous areas which show themselves 
intolerant toward any active form of medication. 

A reflex nervous action on the skin has been held responsible 
for the temporary predisposition to attacks of eczema caused by 
the eruption of teeth, by menstruation, pregnancy, lactation, the 
menopause, etc. 

Regional circulatory disturbances, like those accompanying vari- 
cose veins, for example, may create a manifest local predisposition 
to eczema. 

The pathogenic mechanism according to which these manifold causes 
net i necessarily extremely variable. To formulate it in a few words, 
one woul I be tempted to say that as the process is inflammatory; it 
represents a, defense reaction of the organism against the injurious 
agents which attack the skin. 



ECZEMA, ECZEMATIZATION, ECZEMATOSIS 69 

Although barely admissible for the external causes this general 
idea would not cover the internal causes. Too many decisive 
arguments refute the theory, which is still occasionally admitted, 
however, according to which the skin acts vicariously for other 
emunctories when these are insufficient, and becomes eczema- 
tous under the influence of autogenous poisons, toxins and waste 
products, which seek an outlet through the skin. 

A rather attractive theory was advocated by Jacquet, who 
claimed the intervention of a nervous reflex action of trophic char- 
acter. Visceral lesions or internal disturbances are supposed to 
modify the nervous impulses transmitted to the skin, the resulting 
trophic change enabling the skin to react in the form of eczema 
against strong or even very weak external irritants which would 
have been readily tolerated in the normal state. 

The majority of eczemas undoubtedly result from a combina- 
tion, in variable proportions, of external and internal factors. It is 
therefore imperative, in a given case, to ascertain through careful 
clinical analysis the "etiological dominant" and the accessory 
causes. Only when this requirement is complied with can a rational 
treatment be instituted with some prospect of a successful out- 
come and the prevention of recurrences. 

Symptoms. — When eczema appears suddenly, on a rather exten- 
sive surface, or during an exacerbation in the course of chronic 
eczema, certain general symptoms may be noted, such as digestive 
disturbances and especially malaise, excitement, insomnia, pros- 
tration and a slight fever. 

The eruption is essentially polymorphous; it consists of redness, 
vesiculation, exudation, crusts and scales. Its most characteristic 
feature has very properly been stated to be vesiculation, but 
certain eczemas run their course without at any time presenting 
demonstrable vesicles. 

In a general way, but remembering that, as a rule, several stages 
exist together, the succession of the phenomena may be described 
as follows: At the onset, vivid reddening with diffuse margins 
makes its appearance, showing a very finely granular surface on 
inspection with a lens, with more or less edema, tension and 
pruritus; representing the erythematous stage. It is rare for the 
redness to be absent or to escape observation and for the vesicles 
to appear on healthy skin. The edematous redness sometimes, 
after persisting for a few hours or a day, fades away and leaves 
behind a fine lamellar or furfuraceous desquamation, this being 
observed especially in the face and the genital regions. 

As a rule, a few hours after the onset of the attack, a large crop 
of very superficial vesicles makes its appearance on the erythem- 
atous surface, with transparent contents, from the size of a needle- 



70 



ECZEMA 



point to that of a pin-head, very close together, sometimes becom- 
ing confluent in bullae of moderate size; this is the vesicular stage. 
On the hands and feet, in regions where the epidermis is thick, the 
vesicles are deeper and have less tendency to rupture. They may 
dry in crusts which are gradually eliminated. 

Usually the vesicles do not exist long without rupturing spon- 
taneously or under the influence of scratching and permit the 
escape of a clear, slightly stringy fluid, faintly yellowish or turbid, 
stiffening the underwear like mucilage. The exudative stage may 
be prolonged for several days or even weeks in different cases 




Fig. 8. Ecze 



sts, showing eczema "pores." 



When dressings are employed, the surface of the skin, on removing 
the dressings, is seen to be red or a vivid pink, smooth and perfor- 
ated with superficial round or polycyclic erosions from which 
droplets of a clear sticky serous fluid exude. In case no vesicles 
have been demonstrable, these erosions which are the eezematous 
pores previously referred to, represent their equivalent (Fig. 8). 

In the absence of dressings and when the exudate is not very 
profuse it dries in thin yellowish crusts, or in brown concretions 
when a little blood is mixed with the serum; constituting the stage 
of incrustation, or crusted eczema. 



ECZEMA, ECZEMATIZATION, ECZEMATOSIS 71 

When a pyococcic infection becomes implanted on the eczematous 
surface, which is not uncommon in children or in certain regions 
of the body, the secretion is mixed with pus, the crusts are meli- 
cerous or grayish, thicker and rougher. The surrounding areas 
present the features of genuine impetigo and the case becomes one 
of impetiginous eczema (p. 82). 

The exudate lessens and dries up after a variable time; the 
crusts fall, the surface becomes covered with epidermis; but the 
new horny layer remains thin, transparent, slightly adherent; it 
cracks through desiccation (fissured eczema), and is shed in lamellar 
or furfuraceous scales which are incessantly renewed. 

This stage of desquamation may last a very long time. The 
vesicles are very apt to reappear on the pinkish scaly surface, sepa- 
rately or in groups, continuously or in crops, with a renewal of the 
the exudation and crust formation. 

The persistence of the eczematous process, aggravated by scratch- 
ing, the local conditions of the affected region and the general 
health of the patient, tends to produce a thickening of the patches, 
with elevation and induration. The normal folds and lines of the 
skin are more pronounced, the surface is dry and roughened, scaly 
or crusted. This condition is designated as lichenified eczema. 

Eruptive Varieties. — It is uncommon for the various stages of 
the eczematous process to follow a regular course; as a rule, they 
intermingle, blend and exist together in the same patient. How- 
ever, it must be admitted that certain eczemas, or rather the eczemas 
of certain patients, preferably assume one or other objective form 
and persist a long time at one of the stages, the characteristics of 
which are then especially well marked. 

The varieties of the eruption which require special mention are 
the following: 

Vesicular eczema, with constantly renewed vesicles, occurs espe- 
cially on the extremities. A special type has been distinguished 
under the name of dysidrosis. 

Exudative eczema, with continuous exudation, is observed in 
gouty or obese persons especially on the legs and arms, in the new- 
born on the face, sometimes as the result of irritative applications. 

Eczema rubrum is the form in which the reddening is intense 
(often edematous) and does not completely disappear under 
pressure of the finger, indicating an abundant diapedesis of red 
corpuscles in the cutis. It occurs in extensive patches in acute 
attacks, or is persistent and indolent, on the legs, on the large folds 
and also in the face. 

The term erysipeloid eczema is sometimes employed to desig- 
nate sudden inflammatory and edematous attacks, sometimes 
followed by vesico-bullse, affecting especially the face and the genital 



72 ECZEMA 

organs. It is frequently a complication of a dry sluggish eczema, or 
the result of an artificial local irritation. 

Dry eczema, which in exceptional cases is arranged in circum- 
scribed spots or patches, often polycyclic, with a pinkish scaly sur- 
face, without demonstrable vesicles, is so common and so peculiar in 
its appearance and behavior that there is a strong temptation to 
place it in a group by itself ( seborrhoeic eczema, seborrheid, psoriati- 
form parakeratosis, etc.). It will be discussed at length under the 
name eczematides in the chapter on the erythemato-squamous 
dermatosis (V, p. 90). 

Squamous eczema, in which desquamation is abundant and con- 
tinuous, is encountered especially in individuals or regions with 
defective nutrition. 

Horny, or keratotic or tylotic eczema is practically limited to the 
plantar and palmar regions (XI, p. 214). 

Lichenified eczema, often circumscribed, very pruriginous and 
chronic, seems to be likewise connected with special local condi- 
tions. Its differentiation from eczematized prurigo is sometimes 
very difficult (p. 489). 

Imjietiginous eczema, more common in children and in the arti- 
ficial dermatitides may give rise to folliculitis, furuncles, adenitis, 
lymphangitis and abscesses, in short, to all the manifestations of 
pyodermatitis (p. 82). 

Varieties of Configuration. — The distribution and extent of ecze- 
niatous eruptions are extremely variable and not easily classified. 
The most usual configuration is in form of spots, patches or 
surface lesions of very unequal size and quite irregular contours, 
in geographical or archipelagous designs. This type, designated 
as amorphous eczema by Devergie, is entitled to the name of 
eczema uulgare. 

The so-called papulo-vesicular eczema of Brocq is characterized 
by the fact that its initial element is a small papulo-vesicular 
elevation, instead of a simple vesicle; the confluence of these lesions 
results in patches with an indurated base. The eruption is gene- 
rally widely scattered and develops in successive crops. There is 
intense itching and the relation of this form to the prurigos is very 
evident in certain cases. Frequently, however, this va r iety is com- 
bined with eczema vulgare in other regions of the body. 

Nummular eczema assumes the form of round or oval, sharply 
circumscribed spots, which are sometimes herpetoid (I nna) or 
trichophytoid (Sabouraud). It is common on the wrists, on the 
dorsal aspect of the hands and on the legs. [The patches are 
remarkable for the absence of peripheral extension, their recurrence 
throughout a number of years and the association of moderate 
eosinophilia.J 



ECZEMA, ECZEMATIZATION, ECZEMATOSIS 



73 



Varicose eczema and paratraumatic eczema of war wounds are 
noteworthy on account of their distinctly outlined borders, their 




Fig. 9. — Paratraumatic eczema, following on a bullet-wound of the right arm 
of three months' standing, cured in fifteen days. Noteworthy case on account of the 
arciform and syphiloid configuration of the eruption. Note the central cicatrization 
and the extension by vesico-pustules, especially on the convexity of the border at the 
base of the figure. 




Fig. 10. — Eczema of the papulo-vesicular type on the forearm. 



usually polycyclic configuration, and their continuous peripheral 
extension; they are apt to be combined with impetigo. 



"4 



ECZEMA 



The eczema marginatum of Hebra is a parasitic epidermatitis due 
to the epidermophyton (p. 52 ! i. 

Disseminati ■ eczema will he considered in a paragraph 

by itself (p. s 7 . 
' Generalized eczema will be discussed with the erythrodermas 
,,. 120 and eczema foUicuhriim in the chapter on the folliculoses 




ged six years 



Regional Varieties. On the scalp, especially in children, eczema 
is often incited by pediculi and associated with pyodermatitis; in 
youthful individuals and in adults it is ordinarily a, complication 
of pityriasis and there are imperceptible transitions between dry 
pityriasis, steatoid pityriasis, dry, exudative and crusted eczema 
(see Kerosis, p. 196). 

In the beard and hairy regions the same relations with pityriasis 
are noted. The eczema may be of the exudative type and often 
gh es i ise t" p> ococcic \\ cosis. 



ECZEMA, ECZEMATIZATION, ECZEMATOSIS 75 

Orbicular or orificial eczemas are dry or exudative, often very 
obstinate and are caused or maintained by lesions of the mucous 
membranes and corresponding cavities; they have been interpreted 
as of reflex origin. On the lips, a bad condition of the teeth, irri- 
tating tooth-pastes, pharyngitis, etc., may be responsible. 

Persistent desquamation of the red border of the lips forms a special 
type of unknown character which has been referred by some writers 
to psoriasis, seborrhea, etc. 

On the nostrils, eye-lids and ears conditions are involved such 
as chronic coryza, sinusitis, ocular disturbances and otitis media 
or externa; in eczema of the vulva, the trouble may be due to 
diabetes, cystitis, vaginitis, or metritis; in eczema of the anus, to 
hemorrhoids, fissures or constipation. 

Perigenital and peri-anal eczema very frequently follow on 
pruritus of these regions. 

Generalized eczema of the face, extending to the neck and thorax, 
is often incited in adults by dyes for the hair and beard, or is the 
result of an occupational dermatitis. In children it is often recur- 
rent and related to digestive disturbances or the eruption of teeth. 

Eczema affecting the nipple and areola, in women, is often 
weeping, limited, very obstinate and almost exclusively produced 
by scabies (Fig. 150), or pregnancy and lactation. It must be 
carefully differentiated from Paget's disease of the nipple. 

Eczema of the large folds localized in the articular, submammary, 
subabdominal and intergluteal folds, etc;, is not uncommon in 
obese, diabetic or gouty subjects; it is exudative and diffuse, or 
dry and marginate. 

Intertrigo eczema of infants (p. 31) represents a higher degree of 
irritative reaction than simple intertrigo erythema. 

On the legs, eczema is observed very frequently and in all its 
forms; it is associated with varicose veins, traumatic lesions, ulcers, 
etc., and leads secondarily to dermatoscleroses and hypertrophies. 

On the hands, tvrists and forearms the majority of eczemas are 
caused by external occupational toxidermias; further on I shall 
discuss dysidrosis, which affects also the feet. 

Between the toes, it is common to find a red pruritic dermatitis, 
with exfoliation of large macerated horny shreds. This form has 
been grouped under eczema, dysidrosis or intertrigo by different 
writers; Sabouraud has shown that it is usually parasitic and due to 
the epidermophyton inguinale. 

The question of eczema of the mucous membranes is a mooted 
one. Undoubtedly, eczema exists on the semimucosa?, the red 
border of the lips, glans penis, labia majora and minora. But in 
the mouth, on the tongue, in the nasal fossae, on the conjunctivae 
and in the vagina, the reactions caused by eczematogenic factors 



76 ECZEMA 

are clinically and histologically different from those noted in the 
skin. 

Course and Prognosis. — The course of eczema in general is extremely 
variable. Authors recognize an acute and a chronic eczema, accord- 
ing as the eruption appears abruptly and subsides in a few weeks, or 
becomes locally established and recurs during a period of months 
or years. This distinction is arbitrary and useless. 

The prognosis of a given eczema depends in part on its cause 
and in part on the patient's state of health, namely the degree of 
predisposition present; the latter is often recognized only a 
posteriori. 

In a general way, it may be stated that it is the nature of eczema 
to advance in attacks or relays (e/cfeyuo:, ent;eiv, to boil over or 
effervesce). Eczema begins most frequently but not always with 
a sudden hyperemic attack with general malaise in its course; it is 
the rule that new paroxysms and rapid extensions occur at variable 
intervals, readily provoked by external or internal disturbances. 
Tins "tendency to react toward irritants by an increased exuda- 
tion and inflammation" is so characteristic that Unna included it 
in his definition of eczema. 

During the intervals of the attacks there may be progressive 
improvement, or simple persistence, or progressive aggravation; or 
pyodermic, lymphangitic, etc., complications may make their 
appearance. 

Eczema may constitute a real infirmity, preventing employment 
in a number of occupations. The pruritus and desparation caused 
by it have sometimes resulted in cachexia or even led to suicide. 
Fatal cases for which eczema has been held responsible, are probably 
referable to visceral diseases of which the eruption was merely one 
manifestation (see Kczematosis). 

Diagnosis. It would be an endless task to point out all possible 
errors. I snally, moreover, the diagnosis of eczema is clear, through 
the demonstration of a polymorphous epidermodermatitis, assum- 
ing one or several of the above described clinical aspects and 
arranged in spots or patches with irregular margins. Vesicles 
should not be credited with a greater diagnostic value than the other 
elementary constituents, the process as a whole being the charac- 
teristic feature of the disease. 

Greater difficulties arise in elucidating the cause and origin of the 
eczema. The points to be determined are these: Is the eczema 
purely external and, as it were, traumatic; is it primary, originating 
in the healthy skin, or secondary to a preceding dermatosis; what 
is the part played by predisposition, local or visceral affections or 
the general condition of the patient? The beginner's task will be 
facilitated to some extent, I hope, by the comments which follow 
on some of the principal types. 



ECZEMA, ECZEMATIZATION, ECZEMATOSIS 77 

Treatment. — Limitation is imperative in a field of such magnitude, 
so that only a few brief practical directions will be presented. 

All cases of eczema should be treated because the patient is 
uncomfortable and is threatened with the danger of the eruptions, 
extending as well as becoming infected. The dread of internal 
"repercussions" is largely imaginary; although experience has 
shown that in very extensive eczemas, in those due to grave organic 
or nutritional changes, or which show evidence of vicarious or 
substitution phenomena mentioned above, it is advisable to apply 
only clean dressings or very mild soothing lotions and to avoid all 
active medication. 

Two important rules are as follows : In every case of eczema, the 
physician must in the first place analyze the probable causes of the 
eruption, systematically and with strict attention to detail. To 
begin with, external irritants are looked for and eliminated as far 
as possible; next, preexisting dermatoses, with their marked bear- 
ing on the prognosis and treatment and finally, internal causes, 
which should be controlled by means of appropriate measures. 

The second, equally important rule is that the treatment of 
eczema must be symptomatic and flexible, rather than systematic 
and predetermined. By this statement is meant that the erup- 
tion should be treated according to its behavior, instead of blindly 
applying one or other formula or medication of " anti-eczematous" 
repute. 

Local Treatment. — Acute eczematous attacks require complete 
rest, or at least rest of the affected region, with a prescription of 
simple lotions or spraying with vegetable infusions, or very mild 
antiseptic solutions and generous applications of neutral powders 
which favor desiccation; these can be alternated with cooling 
creams. Salves and pastes are all objectionable at the beginning 
of an acute attack, as they have a tendency to "heat" the skin 
and to macerate the epidermis. 

In the presence of a crusted or impetiginous eczema, the crusts 
should always be removed in the first place and this is accomplished 
by means of lotions with a vegetable or astringent decoction, 
such as very dilute Alibour water (see Therapeutic Notes § 2), or 
the application of dusting powders, preceded if necessary by moist 
dressings [with Liq. aluminis acetatis, 1 : water 10] or aseptic 
softening poultices. When the surface is clean and the inflammation 
has subsided, treatment is begun, while continuing the use of lotions 
twice daily — with applications of ichthyol pastes, with a small 
addition of resorcin or yellow oxide of mercury pastes; sometimes 
bland powders, glycerol of starch or watery pastes prove useful. 

In cases of oozing and itching eczema, painting with an aqueous 
solution of silver nitrate (1 : 10 to 1 : 30) repeated every two or 
threeMays, is*sometimes effective. 



78 ECZEMA 

When the eczema is only slightly inflammatory, without exu- 
dation, but squamous or lichenoid, treatment may begin — after 
thorough cleaning with vaseline or as is my custom, with petroleum 
ether — with the series of pastes, then ointments, made with tar, 
sulphur, weak or strong reducing agents, mercurials, etc., starting 
with the weakest and passing up to pure tar, topical applications of 
chrysarobin or pyrogallol and compound plasters. In case an 
excessive reaction follows, milder measures should be temporarily 
resumed. The most experienced dermatologists usually employ 
strong topical applications very guardedly . The recommendation 
to make use of only the simplest and best tried remedies cannot be 
overemphasized. 

The treatment of dry, psoriatiform and hyperkeratotic eczemas, 
and of pruriginous eczemas, is the same as that of other dermatoses 
presenting the same characters. 

Mention must finally be made of a few topical applications of 
more exceptional employment, which sometimes yield very favor- 
able results. 

Continuous and direct applications of caoutchouc, or better of 
caoutchouc-covered cloths, have enjoyed a considerable vogue, 
but they are often badly tolerated and it is difficult to determine 
just when their employment should cease. 

Contrary to what might be expected strong compound ointments, 
such as those [of tar and sulphur or even tar and chrysarobin] of 
the type of Baissade's balsam (Therapeutic Notes, § 7) [or Dreuw's 
ointment] are efficient not only in the obstinate forms, but also in 
tin case of acute and weeping eczema. Dind (of Lausanne) has 
shown that crude washed coal tar can be employed under the same 
conditions; painted on, then dusted with talcum powder, it forms 
on drying a coating which is left in place for three to eight days; 
this inexpensive, convenient and highly keratoplastic agent has been 
generally adopted and has rendered excellent service. 

The indications for electrotherapy in the form of static baths or 
high-frequency currents are imperfectly understood. These pro- 
cedures are less valuable than radiotherapy, which possesses a high 
degree of efficiency in very pruriginous and lichenoid eczemas as 
well as in the eczemati/.ed prurigos. However, it is resorted to 
only exceptionally in localized and very obstinate cases. [The 
.T-rays are valuable in all forms of eczema except the acute, not 
only for their antipruritic effect but also for their action on the 
infilt rations.] 

(lateral Media/linn.- There is no specific for eczema, but in 
nearly all these patients, it is necessary to intervene for the regu- 
lation of hygienic conditions and the control of the existing tendency 
to nutritional or visceral disturbances, if any such be disclosed. 



ARTIFICIAL ECZEMAS 79 

The diet, restricted in quality as well as quantity, should be that 
of the congestive and pruriginous dermatoses of autotoxic origin. 
A vegetable or milk diet is sometimes necessary. 

Constipation and digestive disturbances must be carefully 
regulated. It is sometimes essential to train the patients to eat 
slowly and chew their food well (bradyphagia) ; it may be necessary 
to insist on the services of a competent dentist for the repair of 
teeth or the fitting of dental plates. 

General hygiene, a quiet life, physical, mental and moral rest 
and sojourn in the open air, if possible, are of course very desirable. 

As to internal medicinal treatment, this varies in different cases 
and may consist in the prescription of alkalis, cod-liver oil, calcium 
salts, phosphates or phosphoric acid, iron or arsenic; exceptionally, 
in opotherapeutic remedies (such as thyroid, suprarenal, hepatic, 
ovarian, intestinal extracts, etc.). 

Arsenic medication, formerly considered indispensable in every 
case of eczema, has greatly fallen in repute and as a matter of fact, 
arsenic is more apt to be injurious than useful, especially in the 
acute forms. As a tonic it may be advantageously employed in 
sluggish eczemas and in weakened nervous patients. I agree with 
the majority of dermatologists, in preferring the sodium arsenite 
to the cacodylates, methyl arsenites or analogous preparations. 

It is difficult to state in a few words what mineral waters are 
suitable for eczematous patients. In a general way, the lymphatic 
group may be referred to sulphur springs; the gouty to alkaline 
and silicate springs; nervous irritable persons are benefited by 
waters charged with calcium sulphates; nervous patients suffering 
from auto-intoxication do well on so-called neutral and sedative 
waters; long-standing cases of the dry and lichenoid type may 
employ arsenical waters. 

Some of the most frequent clinical types of eczema are entitled to 
a special discussion: 

ARTIFICIAL ECZEMAS. 

Their special features depend upon their cause, localization and 
evolution. 

The irritants most apt to incite an eczematous reaction and the 
occupations which most often lead to its occurrence are discussed 
in the chapter on the artificial dermatitides (pp. 463, 467). 

The artificial eczemas naturally develop first of all in the regions 
directly exposed; on the hands, especially in the interdigital folds, 
on the wrists and forearms, in cases of occupational eczema (see 
Figs. 8 and 144) ; on the face and neck, in dermatitis due to dyes, etc. 



SO ECZEMA 

They have a tendency to spread by peripheral extension, but 
may also advance in leaps, reaching, for instance, the face, the neck, 
the thighs or the genital regions. 

Several explanations of these transferences have been sug- 
gested. The injurious substance was assumed to have been trans- 
ported, for example, by the patient's fingers, which is possible in 
certain cases; or the toxic agent was believed to have undergone 
absorption, manifesting it^ effect from within outward, in predis- 
posed regions; again, the eruption at a distance was interpreted as 
the result of a reflex action, although it is hardly likely for a true 
inflammation to be the result of a purely nervous pathogenesis. 
The most plausible explanation, in my opinion, is that which 
regards the [reflex] diffusion of the pruritus as the predisposing 
cause and the scratching or the transportation of the microbic 
invaders of the first eczematous focus, as the determining cause. 

The artificial eczemas are often distinctly vesicular from the 
start; or they may be erythemato-edematous or even erysipelatoid, 
quite at the beginning, becoming vesicular secondarily. They are 
very commonly infected by pyococci and become impetiginous in 
places, while elsewhere they become keratotic, present fissures and 
cracks, become covered with crusts and assume a nummular or 
lichenoid appearance. Extraordinarily polymorphous but never- 
theless characteristic appearances are the result, such as those to 
which special names like grocers' itch, bricklayers' and cement- 
workers' itch, etc., have been given. 

Sometimes, sublata causa, a cure follows with the greatest 
rapidity and almost without treatment; cases of this kind are 
described as traumatic eczematiform dermatitides. However, all 
intermediary degrees occur between this contingency and that of 
prolonged persistence, with recrudescence without apparent cause 
and with invasion of and establishment in remote areas, represent- 
ing a true eczema, originating from a focus of local irritation. 

Even when a more <>r less rapid cure is obtained, the patient 
remains predisposed to recurrences under the influence of the same 
cause in- analogous causes through the effect of a sensitization 
which has been compared with anaphylaxis; and a change of 
occupation may become imperative. 

INFANTILE ECZEMAS. 

In lii tic children, especially between the second to the eighth 
month, eczemas of rather peculiar etiology, topography and evolu- 
tion arc observed with great frequency 'in 5 or 10 per cent, of 
children in Paris). These children are apt to have eczematous, 
neuropathic, intemperate or overworked parents. Their diet, 



SECONDARY ECZEMATIZATION 81 

whether they are breast-fed or raised by hand, in the presence or 
absence of evident digestive disturbances, may be injurious by its 
quality, its too frequent repetition and especially, as has been 
shown by Marfan, through an oversupply of food. It must be 
watched and regulated according to the requirements in a given 
case. Weaning, when carefully managed, is not particularly 
dangerous in infantile eczemas and may on the contrary lead to a 
cure. The part played by the eruption of the teeth, although it 
has been exaggerated, is evident in many cases; it acts by the con- 
gestions, nervous condition and digestive disturbances with which 
it is associated. Various local causes, bad hygiene of the skin, an 
excessive use of soap, coryza, impetigo, vaccination, etc., may all 
serve as determining factors. 

Infantile eczema affects preferably the face, especially the cheeks, 
the forehead and the lips, while the nose and chin often escape. 
Sometimes it begins on the healthy skin in a distinctly vesicular 
form, followed by oozing; in other cases it originates in the sebace- 
ous ducts of the scalp and forehead, where it is known as "milk- 
crust," forming a continuous series from pityriasis simplex to dry, 
impetiginous, or even exudative and crusted eczema; sometimes 
again, although the two preceding forms are likewise, as a rule, 
accompanied by erosions, the eruption is obviously secondary to a 
primary localized pruritus and to the scratching provoked by it. 

This eczema may remain localized, or it may extend as far as the 
buttocks, the limbs and the trunk. The general condition often 
remains excellent and the eruption usually stops and disappears 
about the middle or end of the second year. 

Its etiology, localization and course differentiate true infantile 
eczema from eczematiform dermatitis, usually sta r ting from the 
buttocks, which has been referred to above; the latter represents 
merely an advanced degree of intertrigo-erythema and is entitled 
to the designation of intertrigo-eczema. 

SECONDARY ECZEMATIZATION. 

Eczematization which develops on the soil of other dermatoses 
and is provoked by the same, seems to be the cause of much con- 
fusion in the classical picture of eczema. Familiarity with this 
mode of origin of eczema which depends on the so-called pre- 
eczematous dermatoses is of the greatest practical importance for 
the clinician as in a large number of cases it enables the clinician 
to make a correct diagnosis and prognosis and to institute pre- 
ventive treatment. Moreover, on the assumption that eczema is 
merely a mode of cutaneous reaction, the theoretical explanation 
of these facts meets with no insurmountable difficulties. 



82 ECZEMA 

Eczema and Impetigo. The relations of impetigo to eczema are 
complex and have given rise to various interpretations. Clinical 
findings are rendered intelligible on the basis of the following 
considerations : 

Impetigo or superficial pyoeoccic infection of the epidermis is 
very frequently grafted on an existing eczema, whatever its origin, 
external and artificial or internal and constitutional. The result is 
a modification of the clinical aspect of the eczema, the secretion 
becoming purulent and the crusts melicerous and coarse, consti- 
tuting impetiginized eczema. The neighboring lesions or auto- 
inoculations, the result of scratching, may be the lesions of eczema 
or the pustules of impetigo, or a mixture of the two. 

Conversely, impetigo may give rise to eczema, in this sense that 
the pyoeoccic agents of impetigo under certain conditions (prob- 
ably when they possess a high degree of virulence) and in certain 
regions, are capable of giving rise to epidermodermatitis of the 
eczematous type like other irritants. This microbic eczema, 
which might be called impetiginous eczema, unlike impetiginized 
eczema, lacks constant characteristics and I believe it may assume 
the aspect of a vesicular or oozing, crusted or squamous eczema, or 
even that of dry eczema. The investigations of Sabouraud have 
even led to the conclusion that pityriasis simplex may be regarded 
as a "dry impetigo." 

This second proposition will hardly be admitted offhand ; although 
it is based upon a number of histological and bacteriological exami- 
nations carried out in my laboratory with careful analysis of clinical 
cases and is, I believe, in harmony with the existing facts. 

Eczema and Kerosis. The pathological conditions of the epidermis 
known as pityriasis and seborrhea, grouped by me under the heading 
kerosis (p. 196), create a territory peculiarly predisposed to eczema- 
tization. Most commonly, an eczematide or dry eczema develops 
under these conditions, but this dry eczema has a marked tendency 
to react in the form of exudation and extensive inflammation under 
the influence of scratching, injudicious treatment, or other local 
and general causes; constituting the eczematized seborrheic! of some 
authors. 

Vesicular, oozing, crusted, impetiginous eczema may likewise 
become established from the start in cases of kerosis. The sites 
of predilection of kerosis, primarily the hairy scalp, the face and the 
large articular folds, are naturally also the usual starting-points of 
these eczemas. 

The kerotic origin of eczema is so common that according to 
I'nna, the great majority of eczemas would be suppressed by 
treating and curing seborrheal eczema in its early stages. 



ECZEMATOSIS 83 

Eczema and Prurigo. — Pruritus and prurigo, diffuse or localized, 
of variable origin, are conditions very apt to become eczematized 
and the starting-point of more or less extensive and generalized 
eczemas. Scratching, through its mechanical action and the 
resulting microbic inoculation, constitutes the pathogenic factor 
in this complication, which is met with in the urticarias and in 
scabies. However, not all scratched prurigos become eczematized, 
but have rather a tendency to lichenize, indicating that a certain 
degree of local or general predisposition is necessary. 

It must not be overlooked, on the other hand, that primary 
eczema is itself pruriginous and becomes lichenized under certain 
conditions of persistence, localization and soil. The relations of 
eczema with the pruriginous dermatitides are accordingly complex, 
the particular cases requiring careful analysis. 

Aside from these three conditions in which eczematization is 
extremely common, a long list of dermatoses should be men- 
tioned which, although less frequently, may become complicated 
by eczema. 

Mycosis Fungoides. — Mycosis fungoides includes patches of lichen- 
oid eczema among its common initial symptoms. The exfoliating 
erythrodermas are often eczematized, especially in the folds. The 
ichthyoses and hyperkeratoses are likewise subject to eczematiza- 
tion. Hyperidrosis and intertrigo-erythema mustalso be mentioned 
among the pre-eczematous dermatoses. 

ECZEMATOSIS. 

Under this name I designate the chronic, constitutional or 
dyscratic disease, in which the eczema eruption is the principal 
manifestation and which is generally designated under the name of 
true eczema or eczema disease. 

Eczematosis is met with at all ages. Certain eczemas of new- 
born infants belong under this heading; in the course of childhood, 
adolescence and youth, it seems to be an attribute of lymphatic, 
anemic or scrofulous individuals; at the age of maturity, it affects 
the overworked, inebriate and intemperate, the wealthy class being 
more susceptible than hospital and dispensary patients. It is 
especially common in arteriosclerotic and senile individuals where 
it becomes a very distressing and often almost incurable infirmity. 
I have often been put on the track of a latent visceral cancer or a 
partial retention of urine, pyelonephritis, etc., by incessant rebel- 
lious attacks of eczema in an aged man. 

In a general way, the etiology of eczematosis is characterized 
by the fact that the local or external causes play a rather un- 
important part, whereas the so-called internal causes together 



84 ECZEMA 

with ;i predisposition of organic or humoral origin occupy the 
first rank. In the presence of eczematosis, visceral lesions and 
chronic intoxications are often demonstrable to such a degree 
that it is difficult to determine the precise cause. In other cases, 
the behavior suggests a sensitization of the patient through mul- 
tiple or polyvalent antigens, rendering him susceptible to slight or 
even inappreciable causes. 

Almost invariably, however, the onset of the eczematosis can 
be referred to a cutaneous traumatism, an accidental local irrita- 
tion, repeated scratching induced by anal or genital pruritus, 
inflamed varicose veins, etc. Or it may take its origin in a pro- 
tracted pityriasis of the scalp, or in an old patch of dry eczema. 
Finally, it is seen to occur, as if through the effect of a "metas- 
tasis" or substitution, at the time of spontaneous or artificial 
suppression of asthma, bronchial catarrh, enteritis, neuralgia or 
rheumatic pains. 

Finally, the most trifling causes, the mildest applications, wash- 
ing with soap, fatty substances and even water may provoke attacks. 
The skin of persons having constitutional eczema seems to have 
become less capable of adjusting itself to external conditions and 
they are attacked by paroxysms on occasions such as a change of 
temperature, season, climate, or humidity of the air, on exposure 
to wind, etc.; briefly, any condition which modifies the state of the 
cutaneous circulation and secretion. 

The clinical picture of eczematosis need not detain us. It will 
suffice to state that the eruption may assume any form and degree, 
and affect any region, as discussed under eczema in general. The 
pruritus is variable in degree, often intolerable, paroxysmal and 
especially nocturnal, contributing on the one hand to the main- 
tenance of the lesions through the scratching caused by it and on 
the other to the depression of the nervous system and the morale 
of the patient. 

Notwithstanding intelligent and scrupulous treatment, a cure 
cannot always be obtained, or it is only temporary and followed by 
recurrences. It is very common for these recurrences or renewed 
attacks to start from an imperfectly extinct focus, a focus of microbic 
growth according to the adherents of the parasitic theory of all 
eczemas. The disease lasts years and sometimes till death, w r hich 
may occur in consequence of the organic lesions back of the erup- 
tion, such as Bright's disease, arteriosclerosis, chronic bronchitis, 
cancer, diabetes, etc. 

It frequently happens that the eczema disappears at the moment 
where the terminal complications supervene, and quite naturally 
so, because the exhausted organism is no longer capable of respond- 
ing with a cutaneous reaction. The fact is generally interpreted 



DYSIDROSIS 



85 



by the laity and by a number of physicians as indicating a reper- 
cussion, a "striking in" of the eruption, the effect being mistaken 
for the cause. 

DYSIDROSIS. 

Under this name, proposed by Tilbury Fox, is designated an 
affection (named cheiropompholyx by Hutchinson) which is gen- 
erally regarded as a special disease, but which to me seems to be 
simply a clinical form of eczema, characterized by certain shades 
in the behavior of the eruption, by its seat and by its course. 




Fig. 12. — Occupational eczema of the dysidrotic types in a hair-dresser aged 
twenty-eight years. 

Dysidrosis is seen especially in the spring, from March to June, 
sometimes in the fall. It recurs in a given case frequently at the 
same time of the year. Patients suffering from it are adults, 
rarely children; they present some of the disturbances referable to 
arthritism; frequently they are dyspeptic, nervous or overworked 
and perspire very readily. The attack may be caused by violent 
exercise or by an emotional disturbance. 

The eruption begins symmetrically on the hands or feet, or all 
four extremities at once; it consists of small or medium-sized vesicles. 



86 ECZEMA 

deeply set in the thick epidermis, appearing without redness but 
with sensations of pruritus, heat, or pain on pressure, sometimes 
very distressing. 

It assumes its most typical aspect on the lateral surfaces of the 
fingers, where the skin is white or pinkish and studded with vesicles 
as if with grains of boiled sago. The vesicles may attain the size 
of a lentil and become confluent in bullae of the dimensions of an 
almond or larger, especially on the palms and the soles. A clear, 
very stringy, neutral or alkaline fluid escapes on puncture; the 
fluid is sometimes turbid and on the soles is usually purulent. 
The vesicles of dysidrosis have not much tendency to open spon- 
taneously and usually dry up in a few days, the epidermis becomes 
exfoliated and is shed, disclosing a smooth pinkish surface which 
does not ooze. The course of an attack lasts from five to twenty 
days. 

The eruption may become infected, impetiginous, especially on 
the feet and give rise to fissures, lymphangitis, etc. It is usually 
symmetrical. It may invade the forearms, the neck, the face, a 
considerable portion of the trunk, or even become generalized when 
it represents what has been called a dysidrotic eczema. 

The pathological anatomy of the vesicles of dysidrosis shows 
round or oval cavities, hollowed out at different levels of the 
rete. Originating in the process of spongiosis, they are filled with 
a moderate leukocytic fluid which causes a pressure condensation 
of the neighboring epithelial cells. They have no relation to the 
sweat channels. The special bacillus reported by I una has not 
been found by others. Briefly, there are no anatomical reasons for 
considering dysidrosis as a special dermatosis. 

Clinical arguments are of no greater value. Artificial eczema, 
when it affects the same localizations or any region with a thick 
horny layer, presents an identical aspect. Generalized dysidrotic 
eczema differs in no way from an ordinary eczema. Nothing 
definite is known as to the causes of seasonal recurrences, which 
are, moreover, inconstant or very irregular. Having excluded, in 
the case of the hands, artificial eczemas caused by turpentine, 
iodoform, poisonous plants or other irritants; at the feet, conditions 
like epidermophytosis of the toes and ordinary eczema, no cases 
are left entitled to the label of dysidrosis. It is therefore my 
belief, shared by .Jadassohn, that this affection is not truly auton- 
omous. According to Kaufmann-Wolf (1914), about one-third of 
the cases somewhat generally labelled as dysidrosis are of a tricho- 
phytic or epidermophytic character. 

There is a desquamation of the hands and feet, a recurrent and 
often seasonal affection, which is referred to dysidrosis in which the 
epidermis dries and becomes detached at scattered points or over 



DISSEMINATED ECZEMA OR MILIARY IMPETIGO 



87 



polycylic surfaces. In my opinion this is connected with general 
nutritional disturbances, auto-intoxications, or latent infections, such 
as chronic appendicitis, dyspepsias, pyelonephritis, etc. 

It is almost superfluous to state that dysidrosis has nothing in 
common with sudamina, or intracorneal vesicles observed on the 
trunk and limbs in cases of fever with profuse sweating; nor with 
hydrocystoma or intradermic cysts, due to dilatation of the sweat 
channels. 

ACUTE DISSEMINATED ECZEMA OR MILIARY IMPETIGO. 

Under this title I describe a clinical type comprising the erup- 
tions which have been named acute disseminated morococcal 
eczema (Unna); miliaria rubra or alba; sudoral eruptions (prickly 
heat, lichen tropicus, etc.). 




Fig. 13. — Miliary impetigo of the back, following profuse perspiration. 



It is possible that this type corresponds to several distinct patho- 
logical entities; at the present time they are inseparable. 

The symptomatology is as follows: In a young adult usually 
of the male sex, one notes the appearance, after profuse sweats 
caused by a rise of temperature, a steam-bath, hard work, or 
after cutaneous irritation such as a sulphur bath, of an acute 



88 ECZEMA 

eruption of red spots, the size of a pin-head, having for their center a 
minute vesicle with turbid contents. There is no induration of 
the lesions, no papular elevation as in eczema of the papulovesicular 
type of Brocq; nor is the eruption follicular. It occurs especially 
on the trunk or the first segments of the limbs. The pruritus is 
variable, sometimes quitesevere. 

Often, but not always, the previous existence of impetigo, impe- 
tiginized or common eczema, furuncles or a suppurating wound, 
can be demonstrated in these patients. 

The course is rapid and under proper care the skin not infre- 
quently clears up in three or four days. Successive attacks may 
also occur. Sometimes, especially in irritated or scratched regions 
one or more foci of ordinary or impetiginous eczema form. 

Histology shows, at a point of congestive and edematous derma- 
titis, a minute blister of the impetigo type (that is, produced by 
cleavage), or of the eczema type (that is, through spongiosis), w T ith 
serous contents more or less rich in polynuclears; sometimes there 
is a combination or a succession of these two processes. It is com- 
mon, but not constant, for the little vesicle to have a sw T eat channel 
for its center, although it does not originate through dilatation of 
one of the canals. A follicular location is unusual. 

Investigations carried out in my laboratory go to show that 
various staphylococci may be found in the lesions, in different cases, 
especially citreus and albus; these are the morococci of Unna. 

In my opinion this is a microbic auto-inoculation, scattered in 
consequence of the maceration of the epidermis by the sweat. 

It win ild be logical to classify this eruption with the impetigos 
on account of its pathogenesis and evolution, rather than with 
eczema, since its lesions are not agglomerated and have no tendency 
to oozing. I am considering it here only because objectively it 
resembles eczema and has no resemblance at all to ordinary impetigo. 

Very simple treatment w 7 ith non-irritating washes and applications 
of bland powders or watery pastes, suffices for a cure. Preexisting 
suppurations should be treated if necessary, and some rest should 
be recommended. 



CHAPTER V. 
ERYTHEMATO-SQUAMOUS DERMATOSES. 

There exists a group of dermatoses characterized by red and 
scaling spots. It might be supposed that the eruptive lesions 
designated by these few words are very common, but this is not the 
case provided the terms be used in a strict sense. The word "spots" 
is here employed in its widest application; by their large dimensions, 
the spots under consideration may be entitled to the name of patches 
or plaques. The redness must be of a congestive, erythematous 
character, disappearing momentarily under pressure of the finger; 
it is circumscribed, limited to the spots and not diffuse. Desquama- 
tion is present from the start and in all cases it is of the powdery 
furfuraceous type though sometimes micaceous or scaly and prac- 
tically always connected with the modified keratinization known as 
parakeratosis. 

This definition accordingly excludes: (1) Red spots which are not 
squamous or only become so later on; these belong to the erythemas 
(I) ; (2) Squamous spots which are not red and which belong to the 
keratoses (XI) ; (3) Generalized or very extensive reddening, which 
is known as erythroderma (VI). 

When the spots are small and manifestly surround the hair follicles, 
I consider them as folliculoses (XIX). 

Erythemato-squamous spots may be secondary to a great variety 
of eruptions, of erythematous, eczematous, vesicular, pustular or 
bullous type; representing, not a genuine eruption, but old and 
deformed lesions about to become macula? (XVI, p. 322). 

I shall here discuss only syndromes of primary erythemato-squam- 
ous eruptions which originate and persist under this form. 

Such are: (1) The eczematides; (2) pityriasis rosea; (3) psoriasis 
and (4) the parapsoriases; to which will be added a few words or 
(5) the psoriatiform syphilides, and on (6) certain epidermomycoses. 

This does not, however, exhaust the list of cutaneous affections 
capable of presenting the same eruptive type. As a matter of fact, 
it may be met with, under special features, in certain varieties of 
lupus erythematodes (XXVII, p. 568) and the tuberculides which 
approach it more or less closely; in leprosy (XXVII, p. 578) and in 
mycosis fungoides (XXIX, p. 657). 



'." i ERYTHEMATO-SQUAMOUS DERMATOSES 

The reader is referred to the corresponding chapters on these 
diseases, which are omitted here in the interest of a more complete 
description. For analogous reasons, the red and squamous spots 
of the palmar and plantar regions, as well as those of the mucous 
membranes, are discussed in the chapter on the Keratoses (XI). 

ECZEMATIDES. 

I propose the name of eczematides, to designate the group of 
erythemato-squamous dermatoses in spots or circumscribed patches, 
commonly called seborrheal eczemas, seborrhoids, or dry eczemas. 

Different authors consider them as related to pityriasis and 
psoriasis or as a type by themselves. 

The relations of these eruptions with seborrhea are inconstant. 
I believe them to be closely akin to eczema, for two reasons: because 
of the clinical observation of imperceptible transitions and because 
histologically the lesions are practically identical. However, they 
cannot be simply incorporated with eczema, for the reason that the 
lesions differ clinically from the latter by the four following proper- 
ties: their usual dryness; the sharpness of their rounded or poly cyclic 
outlines; their very prolonged persistence under the same aspect; 
their very ready curability under the influence of local treatment. 

The name 1 have selected seems to me convenient, indicating the 
affinities and suggesting the special characteristics of these eruptions. 

Synonyms and Historical Data. — In view of their great frequency, 
the eczematides have always attracted the attention of dermatol- 
ogists. They have borne very many names, which prove the 
difficulties encountered in their classification: lichen circumscriptum 
(Willan and Bateman); lichen gyratus (Cazenave and Biett); lichen 
annulatus serpiginosus (E. Wilson); eczema acneiforme and pityriasis 
circinata I Bazin); it is the dry, circinate eczema figuration or "flannel 
eczema" of the dermatologist of the Saint Louis Hospital, the 
eczema marginatum of Pick, Kobner, Ilebra and Hardy, the seborrhea 
corporis of Duhring, the eczema seborrhoeicum of Unna. There has 
always been a tendency to consider these eruptions as of parasitic 
origin. 

The name seborrheal eczema has proved decidedly the most 
popular. Inna, as far back as 1887, not questioning the eczematous 
character of the dermatosis thus named by him, pointed out that 
the eruption preferably attacks the seats of election of seborrhea 
and that, moreover, it -> scales or crusts have a fatty consistence. 
The name coined by him Mas based on these observations. Being 
struck, furthermore, by the fact that all intermediary degrees are 
encountered between these eczemas with fatty scales and pityriasis 
on one hand and certain forms of psoriasis on the other, he was led 



ECZEMATIDES 



91 



to extend immoderately the limits of seborrheal eczema. His 
teachings, originally received with high favor, did not fail to arouse 
severe criticism. On the one hand, the eczematous nature of the 
process was contested, hence the name of seborrhoids, proposed by 
Brocq and Audry; on the other hand, it was demonstrated that this 
process is not invariably seborrheal. 

The group has now been arbitrarily broken up: various con- 
stituents are classified as steatoid pityriasis, by Sabouraud, as 
medio-thoracic dermatosis and psoriatiform keratosis, by Brocq, etc. 




Fig. 14. — Figured eczematide of the interscapular region of the back. 



In my own opinion, the prevailing confusion on this subject would 
practically disappear by keeping in mind: (1) that there exists a 
cutaneous dystrophy which I have named kerosis (XI), ordinarily 
manifesting itself through pityriasis and seborrhea; (2) that this 
kerotic soil is a seat of predilection for the development of various 
inflammatory complications which very frequently assume the 



Ml' 



ERYTHEMATO-SQUAMOUS DERMATOSES 



clinical form of eczematides or sometimes that of moist eczema, 
or still other forms, such as rosacea, acne, etc. 

The eczematides are then-fore interpreted by me as dry and cir- 
cumscribed eczemas, which on account of these characteristics 
deserve to be distinguished from the ordinary eczemas, and which 
in the vast majority of eases, though not invariably, develop on a 
kerotic soil. 




Fig. l ■">. Figured eczematide of the forehead (corona seborrhoica, qoI to be 

confused with the "corona veneris"). 



Symptoms. The eczematides are practically always preceded 
and accompanied in their vicinity by manifestations of kerosis. 
In the mildest degree, it is very difficult to discern if the complica- 
tion exists or not; a judgment must he based on the presence of 
circumscribed and scaly redness. 

Well-developed eczematides possess typical characteristics, differ- 
ing slightly according to their seat and variety. 

1 . Figured Eczematides. This first group corresponds to "eczema 
llanellaire," the petaloid and circumscribed type of Unna, the 
steatoid pityriasis of Sabouraud, the medio-thoracic figured derma- 
tosis of Brocq, the seborrhea corporis of Duhring. 



ECZEMATIDES 93 

The eruption at the onset almost invariably occupies the pre- 
sternal and interscapular regions; from here it extends to a greater 
or less distance from the median line according to its severity and 
duration. It is seen also on the scalp, whence it extends to the fore- 
head, temples and postauricular region. 

The lesions begin as pinkish punctiform spots covered with a 
greasy scale. Next, they spread as nummular, petaloid or poly- 
cyclic, coalescent, more or less numerous spots, having the following 
characteristics: sharply marked outlines; pinkish or bright red, 
often slightly elevated papular borders, covered with yellowish 
scales and crusts which are of a fatty consistence when squeezed 
between two fingers ; a flattened surface, on a level with the normal 
skin, of a yellowish pink color, often covered with scales less thick 
than on the margins; no apparent vesicles and no infiltration of the 
base. Scraping the margin with the finger-nail or with a curette 
causes the appearance, according to Brocq, of a minute purpura, 
droplets of serous fluid and, finally, small punctiform hemorrhages. 

While extending, some of the spots heal in the center or in a portion 
of their periphery. In the zone of invasion, the follicular orifices are 
often attacked first, which explains the name of acneiform eczema, 
proposed by Bazin. Pruritus is moderate and intermittent or it 
may be altogether absent. 

The duration of the eruption is indefinite and patients are not 
uncommonly met with who have suffered from it for twelve or 
fifteen years. Appropriate treatment causes it to disappear in ten 
to fifteen days. 

2. Pityriasis orm Eczematides.- — The characteristic features of 
these cases are less definite. The lesions consist of pinkish or 
yellowish pink spots, with a surface covered with fine scales, dry or 
slightly oily in the kerotic areas and rather distinctly circumscribed. 
Their form is round, oval, or irregular; their dimensions and number 
are very variable. 

The lesions may occur anywhere, but especially on the scalp and 
the neighboring skin, on the neck, the upper part of the trunk, the 
axillae, the groins, the articular folds in general and more rarely on 
the extremities. 

Sometimes the eruption is profuse, more or less symmetrically 
arranged, appearing in rather rapid attacks and composed of 
lenticular, nummular, or more extensive plaques, usually marginate, 
dotting the thorax and the abdomen. Up to a certain point, this 
variety can be recognized in the description of circinate and marginate 
pityriasis (Vidal), of herpes tonsurans maculosus (Hebra, Kaposi) 
and of psoriatif orm parakeratosis in scattered patches (Brocq) . It 
approximates the pityriasis rosea of Gibert. In the absence of treat- 
ment, its duration is from a few weeks to several months. 



94 



ERYTHEMA TO-SQ UA MO US DERMA TOSES 



In other cases the lesions are not numerous, localized without 
symmetry, limited for instance to a large articular fold, developing 




Fig. 16. — Pityriasiform eczematides. 




I [G. 17. 



-Pityriasiform eczematide, with a lichenoid tendency, located on the 
posterior border of the righl axilla in a young woman. 



insidiously, gradually acquiring ;i rather considerable extent and 
persisting indefinitely. The spots, from being at first simply con- 
gestive and furfuraceous, may assume a lichenoid appearance, or 



ECZEMATIDES 



95 



pass into a psoriatiform type; they are apt to present a marginate 
or circinate outline with a yellowish center. 

In both cases, but especially in the localized variety, the pityriasi- 
form eczematides may become temporarily vesicular or oozing 
(eczematized seborrhoids of some authors) ; then they subside again, 
unless they continue to develop into moist eczema. 




Fig. 18. — Psoriatiform eczematides on the hip of a middle-aged woman; note 
that on the trunk the lesions become confluent, as erythrodermia. 

3. Psoriatiform Eczematides. — Their topography and the configu- 
ration of the lesions are entirely analogous to the preceding form. 
But the spots have a brighter red, or tawny hue with a slightly 
infiltrated base, profusely covered with more or less adherent white 
scales. When subjected to the systematic scraping 1 of Brocq, they 
yield, however, less numerous and less stratified lamellae than the 



1 The "grattage methodique" of Brccq consist in the careful scratching of the 
surface of a lesion with the aid of a dull curette; the resulting oozing, bleeding, 
purpura, etc., vary in a characteristic manner in different diseases. — Ed. 



90 ERYTHEMATOSQUAMOUS DERMATOSES 

spots of psoriasis; the red surface, on exposure, is slightly irregular 
and scattered over with purpuric spots, fine hemorrhages, and cup- 
shaped depressions from which a little serous fluid exudes, these 
depressions representing a pathognomonic feature. The lesions of a 
psoriatiform eczematide may be fairly abundant, covering a con- 
siderable portion of the integument (Fig. 18) and even becoming 
regionally confluent in large erythrodermic patches, covered with 
scaly crusts; often they are few in number, or there may be only 
a single large patch on any part of the body; for instance, on the 
neck, in a fold, or on the calf of the leg. 

In this variety, moist eczematization with formation of vesicles, 
oozing and even impetiginization or lichenization is not uncommon. 

Itching may be very severe, a symptom which may lead to pos- 
sible confusion with a partial prurigo. 

There exists finally, (4) a peripilar type and (5) an erythrodermic 
type of eczematides, which will be discussed in the chapter dealing 
with the folliculoses (p. 395) and the erythrodermas (p. 120). 

Diagnosis. — This is by no means easy in all cases. A little atten- 
tion will suffice, however, in the case of figured eczematides, to avoid 
confusion with a desiccated impetigo, with circinate syphilides, with 
lupus erythematodes, etc. 

Pityriasiform eczematides are distinguished from pityriasis rosea 
of Gibert by the often larger dimensions of their lesions and by the 
less systematic evolution of the eruption. There are borderline 
cases, however, in which the question arises if a legitimate distinc- 
tion can be drawn between the two types of disease. Other cases 
suggest a cutaneous trichophytosis; the latter is characterized by 
the perfect roundness of the spots, by their marginal vesiculation 
and by the demonstration of the mycelium on microscopical exami- 
nation of the scales. Syphilitic roseola is never scaly. In psoriasis, 
even when mild, the scales are more profuse. 

The variety with large patches is suggestive of intertrigo-erythema, 
of eczema marginatum of Hebra and of erythrasma; it simulates 
especially a circumscribed eczematized prurigo. When it presents 
oozing, crusts, lichenization and many erosions, the diagnosis can 
sometimes not be made until after treatment for several days. 

Between the psoriatiform eczematides and genuine psoriasis, there 
is no definite objective difference; the distinctive features are based 
on the topography of the eruption, its course, its tendency to oozing 
and on the effect of treatment; the diagnosis in a given case must 
sometimes lie held in abeyance. 

Pathological Anatomy. Although somewhat dissimilar at first 
sight, the histological lesions of the eczematides are always of the 
same kind, no matter what variety be studied, and all transition 
forms are met with between these varieties. 



ECZEMATIDES 



97 



The essential lesions are: Spongiosis, in small foci; parakeratosis, 
often discontinuous; scaly crusts; acanthosis; in the cutis a little 
edema with perivascular infiltration. 




Fig. 19. — Section of figured eczematide. X 27. The central portion of the 
nummular spot is not shown in the sketch, only the two borders of the lesion being 
represented. A, spongiosis; B, crust; C, parakeratosis; D, acanthosis; E, crust; F, 
spongiosis. 

In the figured form (Fig. 19), provided the lesion is in active 
progression and not at a stationary stage, as frequently happens, 
very minute foci of spongiosis, too small to constitute vesicles 
visible to the unaided eye may be seen near the borders or more 
rarely in the center. Originating in the rete, these foci are pushed 
up in the course of the epidermal development as far as the horny 
layer, when their desiccated plasma mixed with the layers of para- 




Fig. 20. — Psoriatiform eczematide. Entire section of a very small lesion. X 30. 
A, spongiosis; B, focus of desiccated spongiosis; C, scale crust; D, parakeratosis; E, 
spongiosis; F, parakeratosis; G, spongiosis; H, papillary edema and congestion; I, 
cellular infiltration. 



keratotic cells gives rise to small lenticular crusts; the latter, in spite 
of their oily consistence, contain less fat demonstrable by osmic acid 
than the normal horny layer. In the center of the spots only a low 
degree of acanthosis is found. Edema of the papillary body and 
perivascular cellular infiltration are marked only near the borders, 
which are abrupt or gently sloping. 

The psoriatiform variety simulates psoriasis, histologically (Fig. 



98 ERYTHEMATO-SQUAMOUS DERMATOSES 

20) as well as clinically. The differences are as follows: The super- 
ficial layer is a thick scaly crust, in which are found, between the 
layers of nucleated horny cells (scales), collections of desiccated 
serum and leukocytes (crusts). The parakeratosis may be con- 
tinuous over the entire lesions, or interrupted. The acanthosis and 
lengthening of the papillae are nearly as marked, although less regular 
than in psoriasis; the crests of the papillae do not reach so near to 
the horny layer. In the papillary body very small foci of spongiosis 
may be discovered here and there, corresponding to a more abundant 
cellular infiltration in the adjacent papillae. These are the foci of 
spongiosis which are destined to become crusts on reaching the horny 
layer. The papillary edema and the perivascular cuffs are a little 
more pronounced than in psoriasis (Fig. 23). 

Summarizing, these lesions constitute an epidermo-dermatitis of 
eczema type, but more discrete, less acute and less edematous. It 
will be readily understood that the exaggeration of the process will 
result in eczema vulgare. 

Etiology.— Eczematides are extremely common. They are 
observed at all ages, especially in the course of adolescence, youth 
and maturity. Many persons suffer from the affection without 
attaching importance to it. A considerable number of eczemas are 
derived from, or begin under this form. 

Clinical analysis had formerly led to the conclusion that the 
dry figured eczemas are parasitic. According to Unna, seborrheal 
eczema is due to morococci, micrococci found in the crusts in mul- 
berry-shaped clusters. Others believe that the seborrhea provokes 
eczema (Dubreuilh), or creates the necessary soil, hence the name of 
seborrhoids. Audry and Brocq, who proposed the last denomination, 
have demonstrated, however, that these eruptions can exist without 
seborrhea. 

The relations between the eczematides and kerosis have been 
discussed above. In my opinion, kerosis creates a peculiar predis- 
position for the attenuated eczematization which constitutes the 
eczematides. In all probability, the complication is the result of a 
local mierobic infection. The responsible species is not yet known, 
whether it be the staphylococcus cutis communis or the poly- 
morphous coccus with gray cultures (Sabouraud), or other staphy- 
lococci; nor do we know if a certain degree of virulence is essential, 
or a certain symbiosis, for example, with the spores of Malassez 
(bottle-bacillus of Unna, microsporon anomaon of Vidal), or if 
there exists a specific microorganism which has so far escaped 
detection. Recent investigations of Du Hois (Geneva) on this 
subject indicate that the scale of the young lesions of pityriasiforrn 
eczematides- which can always be lifted as a whole with a scarifier 
or a fine bistoury — bears on its deep aspect collections of round 



PITYRIASIS ROSEA OF GIBERT 99 

spores, of different dimensions and without mycelium; he was unable 
to grow cultures of this parasite or to inoculate the germ, which is 
probably identical with Vidal's microsporon anomceon or dispar. 
The same parasite is found in the scales of the pityriasis rosea of 
Gibert. The question therefore still remains open. 

Treatment. — Whereas the treatment of eczema and psoriasis is 
difficult and often disappointing, the eczematides usually yield 
favorable results, easily obtained. 

In the sluggish, especially the non-eczematized forms, treatment 
may consist of rather energetic local applications, grading the 
strength of the remedy according to the intensity of the lesions. 

It is often advisable first to clean the spots, namely, to remove the 
scales or crusts. This is accomplished by means of soapy, alkaline, 
or sulphurous baths, by moist dressings, or more simply by washing 
twice daily with white soap, potash soao, or a sulphur or tar soap. 

Directly afterward, or simultaneously, local agents are employed, 
salves, plasters and especially compound pastes, whose active sub- 
stances are selected from the reducing agents: arsenic-zinc-sulphur 
paste or if this be thought too irritant, ichthyol paste, or glycerol 
preparations with ichthyol may be employed. More powerful 
reducing agents may also be used such as chrysarobin or pyrogallol 
in very small doses. 

The psoriatiform eczematides sometimes offer considerable resis- 
tance to treatment. They are managed like psoriasis but with 
doses of progressively increasing strength, and cautiously for fear 
of exciting acute eczematization. Compounds of tar and sulphur, 
for example, and radiotherapy constitute very valuable adjuvants 
in difficult cases. 

On the scalp, sulphur lotions are employed, with ointments 
containing the same active substance. 

Internal treatment, by diet and medicinal agents, plays practically 
no part in the eczematides; or rather, it is identical with that of 
kerosis. 

PITYRIASIS ROSEA OF GIBERT. 

Pityriasis rosea of Gibert — pityriasis maculata et circinata of 
Duhring, roseola squamosa of Fournier, herpes tonsurans maculosus 
of Kaposi — is an erythemato-squamous dermatosis, characterized 
(1) by its lesions; (2) by its topographical distribution; and (3) 
especially by its course. 

Symptoms. — The eruption, which itches severely, slightly or not 
at all, consists of two kinds of lesions. Some are pinkish, scaly, 
irregularly rounded lenticular or nummular spots, with not abso- 
lutely distinct margins; they may become confluent in plaques or in 
patches, 



100 ERYTHEMATOSQUAMOUS DERMATOSES 

The others are more characteristic; known as "medallions," they 
are larger, almost invariably elliptical, pinkish and squamous on 
their slightly elevated borders and have a yellowish center where 
the epidermis is finely puckered as in atrophic strife. These two 
kinds of lesions are present in variable proportions: the larger 
lesions, "medallions" may be rare and have to be looked for or they 
may be absent at a given moment. 

Pityriasis rosea may occupy the entire trunk, the neck and the 
limbs, but it almost invariably spares the face above the chin, the 
hands and the feet. The immunity of the hairy scalp is worthy of 
special mention . The susceptible regions are not affected all at once, 
but symmetrically and nearly always in a certain order. 

The course of this affection is one of its most peculiar features. 
The disease is almost definitely cyclic, so that pityriasis rosea has 
been described as a pseudo-exanthema. 

Frequently — as was first pointed out by Brocq — the eruption is 
introduced by a primary patch, or initial plaque, occupying any 
portion of the trunk, neck, or limbs. It is erythemato-squamous, 
fairly well outlined, more or less pruritic, often circinate, and is 
usually misinterpreted as a patch of trichophytosis or an eczematide. 
Two or three such patches may be present. Judging from my 
persona] experience, the initial plaque remains undetected, or is 
entirely absent, in about one-half of the cases. 

From four to twenty days later, or sometimes from the start, the 
pinkish spots and "medallions" appear in profuse crops, first on the 
upper part of the thorax, on the neck and arms, then on the flanks, 
the abdomen and the thighs, finally on the forearms and sometimes 
on the legs. 

The eruption is accordingly successive, progressive and descend- 
ing. It is afebrile and unaccompanied by disturbances of the 
general health. 

At the end of a month to six weeks, two and a half months at 
most, the spots which begin to fade in the regions first affected, 
disappear completely without leaving a trace behind. 

1 have observed a recurrence of pityriasis rosea at the end of four 
years in the same patient, but this is very exceptional. 

Pathological Anatomy. — The pathological anatomy reveals more 
lesions than might have been anticipated. Aside from a congestion 
of the papillary body, with edema and rather marked perivascular 
cellular infiltration, Sabouraud has pointed out the regular presence 
in the border of the spots, of microscopical foci of spongiosis and 
numerous superficial histological vesicles. The latter are never 
clinically demonstrable and contain only mononuclear leukocytes, 
but apparently no microorganisms. 



PITYRIASIS ROSEA OF GIBERT 101 

The scales are parakeratotic and interspersed with these desiccated 
vesicles. No mycelium or special parasites are demonstrable and a 
remarkable confusion has led Hebra and Kaposi to describe pity- 
riasis rosea as a trichophytosis, under the name of herpes tonsurans 
maculosus. 

Diagnosis. — Pityriasis rosea of Gibert differs from the eczematides, 
by its "medallions," by its symmetrical distribution, by its invariable 
absence from the scalp, and especially by its regular and cyclic 
development, which terminates in spontaneous cure in a definite 
time — though sometimes, the immediate diagnosis must be left 
open; from psoriasis, by its much less vivid redness, its fine non- 
stratified scales and its course; from toxic and infectious erythemas, 
by its "medallions" and its desquamation. 

An unpardonable error, one that may lead to great domestic dis- 
tress, is unfortunately sometimes committed, when a case of pity- 
riasis rosea is mistaken for a syphilitic roseola; the latter is never 
scaly, does not form "medallions" and is associated with a hard 
chancre, mucous patches or at least with glandular enlargement. 

Etiology and Character. — As to its nature and cause, pityriasis 
rosea remains a problem. It is known preferably to attack youthful 
individuals, especially young girls and women; to be more common 
in the spring and fall and in persons suffering from digestive dis- 
turbances. It shows no predilection for cases of kerosis. 

Its initial plaque, its course, its spontaneous cure after a certain 
lapse of time and its non-recurrence, speak in favor of a systemic 
infection . No instances of contagion are known . Long ago, Lassar 
advanced the view that pityriasis rosea might result from an exog- 
enous cutaneous infection, the unknown germ being transmitted 
by new or bleached underwear; Jadassohn believes this view to be 
justified in a number of the cases. 

Treatment.— It is better to omit all treatment of an eruption which 
always heals spontaneously than to aggravate it by the use of soap, 
sulphur baths, or irritative topical applications which congest the 
skin, aggravate the pruritus and sometimes give rise to a real eczema- 
tization. 

Dusting with a bland powder may suffice. It has seemed to me 
that coal-tar in small doses, particularly ichthyol, 2 per cent, in a 
cream or a glycerol, visibly hastened the fading of the lesions. 
Jadassohn recommends chrysarobin pastes of very weak concen- 
tration (1 in 3000 to 1 in 1000); others prefer sulphur pastes, or 
especially aqueous pastes. [Calamine lotion with the addition of 
10 per cent, of precipitated sulphur, or, in very pruritic cases, of 2 per 
cent, of phenol is a satisfactory application.] 



102 ERYTHEMATOSQUA MOl r S DERMATOSES 

PSORIASIS. 

Psoriasis is one of the most important dermatoses, through its 
frequency, the multiplicity and extent of it^ lesions and its rebellious 

character. 

Symptoms. 'Die lesion of psoriasis is typical. In its most 
common form, it is a bright red, sharply circumscribed spot, covered 
with dry, nacreous, laminated, friable and abundant scales; the 
base of the spot is not infiltrated and there is no itching (Fig. 21). 

Scratching these lesions causes two characteristic signs: (1) on 
scratching with the fingernail, the scale breaks down into a fine 
white micaceous dust; (2) after the scale has been removed by the 
fingernail a red shining surface is exposed showing fine punctiform 
hemorrhages. 




Fig. 21. — Nummular psoriasis "ii the wrist, large plaque on the forearm, with 
psoriatic arthropathies of the hand ami fingers. 

The last-named sign, known as Auspitz' sign, the importance of 
which was shown by Hebra and Devergie, has been more fully 
analyzed and worked out by L. Duncan Bulkley and by the recent 
investigations of Brocq. It will he again referred to later. 

It i> frequently demonstrable, on careful inspection, that the 
psoriasis >pots arc surrounded 1>,\ a [talc halo, from 1 to 8 mm. wide, 
the skin of which i> healthy, hut slightly blanched. 

The lesions of psoriasis are usually rounded or oval in shape. 
They may be of au\ size from a pin-point or pin-head, a drop of 
wax, or a coin, to immense patches, covering an entire region of the 
body. As a rule the lesions of the same eruption have rather uni- 
form dimensions, hence the terms psoriasis punctata, [guttata], 
nummularis, discoides, etc., which have merely a descriptive value. 

Sometimes, the lesions have the shape of psoriatic rings, from 
\ to 1 cm. wide, enclosing an area of healthy skin, or fragments of 



PSORIASIS 



103 



rings and arabesque designs, constituting psoriasis gyrata or figurata, 
formerly described under the objectionable name of lepra vulgaris; 
or they may be marginate plaques, the result of healing from the 
centre. 




Fig. 22. — Psoriasis, general topography of the eruption. 



The eruption is accompanied by no general disturbances; psoriasis 
is pruritic only in inebriates and in some nervous subjects. 

The number of lesions is infinitely variable, from a few isolated 
spots to several hundreds. The eruption at its origin appears either 



104 ERYTHEMATOSQUAMOUS DERMATOSES 

as minute red papules which fade even on scratching, or as concen- 
trically growing guttate lesions which rather rapidly reach their 
permanent dimensions, or primarily as patches of nummular size. 

In its distribution, typical psoriasis shows a marked tendency to 
symmetry and a predilection for bony prominences (Fig. 22); the 
elbows and the knees, the scalp and the sacrum (sacral plaque) are 
especially the seats of the largest, most typical and most obstinate 
patches. However, all regions of the integument including the face, 
the palms and the soles, the red border of the lips, and the semi- 
mucosse of the genital organs may be affected, but the mucous 
membranes are always free. The "buccal psoriasis" of the older 
authors is simply leukoplakia (p. 219). 

On the scalp, which rarely escapes and is sometimes the sole seat 
of the affection, the psoriasis spots or patches are characterized by 
their sharp limitation, the abundance of white or grayish scales, in 
a continuous or micaceous layer, covering a red non-oozing surface. 
It is noteworthy that the hairs are preserved, appear dry, pass 
through the scales and do not come out on traction, contrary to 
what happens in the eczematides of this region and in the tineas. 

Varieties. — There occur anomalies of eruptive form or of distribu- 
tion and regional varieties. Sometimes the spots of psoriasis are 
faintly outlined, superficial, light pink and covered with not very 
profuse slightly yellowish scales resembling pityriasis. This attenu- 
ated psoriasis, which is often seen on the face and occasionally on the 
genital organs, is sometimes difficult to distinguish from the eczema- 
tides. 

Psoriasis spots, even when small, may exceptionally have a slightly 
infiltrated base, solid to the touch and almost papular; representing 
infiltrated psoriasis. This modification occurs especially at the 
border of the annular and carcinate lesions of figured psoriasis. 
Somewhat extensive spots or patches of long-standing psoriasis are 
always more or less thickened and sometimes even lichenoid: 
psoriasis inveterata. In certain regions, for example, on the legs, 
the surface exceptionally becomes roughened or papillomatous. 
Frequently, old and figured patches are covered with a nacreous, 
oystershell-like keratotic layer of stratified and adherent scales. 

In other cases, especially in the articular folds, psoriasis may have 
the appearance of vivid red plaques, denuded of scales, or covered 
with crusts, or freely oozing like an eczema rubrum; the borders are 
sometimes irregular. The nature of this oozing psoriasis, or eczema- 
psoriasis of the old authors, is doubtful. Are these cases a special 
form of psoriasis, or are they an eczematized psoriasis, even though 
the integument of such patients is usually very rebellious to artificial 
eczematization; or are they a psoriatiform eczematide? It seems 
probable that there are cases to which each of these interpretations 



PSORIASIS 105 

may be applied. It is not uncommon to find typical spots of psoriasis 
on the elbows and knees of these patient. 

In some cases of genuine psoriasis, the almost exclusive localiza- 
tion on the flexor surfaces of the articular folds, the groins, axillae, 
as well as on the genitals and often on the palms and soles, con- 
stitute a type known as psoriasis inversa. The eruption assumes the 
form of large bright red patches, the skin being smooth and tense. 
It is found in the victims of diabetes, overexertion or intoxication. 
It is often very obstinate and apt to become irritated by any form 
of medication. 

This variety more often than the typical forms, becomes associated 
with secondary erythrodermas of the benign or malignant "herpe- 
tide" type (p. 122); sometimes, the onset of this complication is 
attributable to badly tolerated medicinal applications. 

The distribution which is indicated in the names of palmar and 
plantar psoriasis (p. 215); ungual psoriasis (p. 435) and psoriasis 
universalis (p. 120), will be described in other chapters. 

A very important clinical form because undoubtedly the most 
serious, is the arthropathia psoriasis, studied especially by Bourdillon. 

The frequency of articular manifestations in psoriasis is estimated 
at 5 per cent, of the cases; and in my opinion this estimate is too low. 
[They are by no means so frequent in America]. Often, these are 
merely arthralgias, myalgias and melalgias, resembling indefinite 
subacute rheumatism; this is psoriasis dolorosa. In other cases, 
either dating from the first eruption or after the lapse of a few 
years, progressive nodular, bony or fibrous arthropathies super- 
vene, affecting the joints of several fingers (Fig. 21), one or more 
large joints and sometimes entire limbs and the vertebral column, 
leading to deformities with ankylosis and contractions which con- 
stitute most painful and deplorable infirmities. 

The differential feature of these arthropathies from those of mul- 
tiple arthritis deformans — with which they have many analogies — 
aside from their coincidence with the eruption, is their predilection 
for the male sex, youths and adults rather than old men, their more 
abrupt course, the frequent presence of hydrarthroses and the pre- 
dominance of swelling among the deformities; finally, the absence 
of all regularity of the invasion. These features likewise charac- 
terize the tuberculous pseudo-rheumatism of Poncet. 

Arthropathic psoriasis, being too common to admit of an explana- 
tion by simple coincidence, constitutes an argument for certain 
authors in favor of a nervous origin, for others (Audry, Petges, etc.) 
in favor of the tuberculous origin of psoriasis, or rather of certain 
forms of psoriasis. 

Course. — Psoriasis runs its course in more or less abrupt attacks 
in different cases and is of very variable duration. The first attack 



100 ERYTHEMATOSQUAMOUS DERMA TOSES 

is often more acute and composed of many small lesions, but this is 
not an absolute rule. Subsequent attacks supervene without any 
regularity and often in the absence of a demonstrable determining 
cause. 

In the interval between attacks, especially under the influence of 
appropriate treatment, the patient is "bleached," in the sense that 
the lesions fade, sometimes leaving a dark deep-pigmented macule 
which persists a few months before it disappears. Such patients, 
however, are by no means to be considered as cured. 

Sometimes, two or three more obstinate spots resist all therapeutic 
efforts and persist indefinitely. It is moreover in the nature of the 
disease to recur during almost the entire lifetime of the patient. 
The skin rarely remains perfectly free for more than two or three 
years in these cases. There are innumerable cases of discrete psoriasis, 
without severe attacks, but incessantly persistent or recurrent. 

In aged persons, the disease becomes attenuated or extinct, some- 
times leaving behind it a sort of persistent pityriasic desquamation. 

Diagnosis. — This is based on the characteristic features of the 
lesions, those of the eruption and of the disease. The properties 
belonging to the psoriasis spot cannot be over-emphasized. Their 
recapitulation here is unnecessary, but on account of their great 
importance, I must refer again to the data furnished by systematic 
grattage according to the method of Brocq. 

In a typical lesion of psoriasis, under the successive layers of 
micaceous scales, a red and smooth surface is reached, from which 
a fine pellicle can be detached, coming off in shreds several centi- 
meters square; underneath it fine droplets of blood exude, sometimes 
after a little lapse of time; but purpuric spots are rare and no drops 
of serous fluid are obtained, as in the eczematides. 

As regards the eruption, without referring to its customary dis- 
tribution, it is to be noted that in psoriasis, all the lesions are psorias- 
iform, a condition which is not found in the diseases which simulate 
it (psoriatiform syphilides, etc.). 

It would be superfluous to dwell on the differential features dis- 
tinguishing psoriasis from lichen planus, lichen corneus, premycotic 
patches, Lupus erythematodes, pityriasis rubra pilaris and the other 
erythemato-squamous dermatoses treated in this chapter; these 
differences will be manifest from the description of these various 
affections. 

Pathological Anatomy. — The principal lesion of psoriasis is para- 
keratosis, or change of keratinization characterized by the disappear- 
ance of the stratum granulosum and by the persistence of flattened 
nuclei in the cells of the horny layer. The horny layer is also less 
oily than in the normal state, its stratifications accumulate, but are 
easily split into lamellae (Fig. 23). 



PSORIASIS 107 

The rete is hypertrophied and considerably thickened (acanthosis) 
between the papilla? which are greatly elongated and cylindrical 
(papillomatosis) ; but it is thinned above the crests of these papillae 
which are separated from the parakeratotic horny layer only by a 
few layers of flattened cells. The papilla? and the papillary body are 
slightly edematous and their bloodvessels are dilated and surrounded 
by a small number of round cells; the lesions of the derma are insig- 
nificant. 




.. < '. ' :.' :V 







Fig. 23. — Histology of psoriasis. General section of a small but long standing 
lesion of the elbow. X 50. A, parakeratosis; B, acanthosis; C, papillomatosis; D, 



These changes explain the clinical symptoms; the redness is refer- 
able to the congestion, to the elevation of the papillary crests and 
to the absence of an opaque keratohyaline layer. The desquamation 
and the peculiar powdery scaling evident upon scratching depend 
upon the cleavage and the friability of the parakeratotic horny layer. 
The smooth sub-squamous membrane is made up of the layers of 
flattened Malpighian cells; it is due to the slight thickness of this 
layer and its softness that the adjacent vascular papilla? are easily 
injured with the nails, whence the punctiform hemorrhages. Acan- 
thosis and infiltration are more marked in inveterate psoriasis with 
more or less lichenoid patches. 

The parakeratosis, owing to which the epidermis is now composed 
of only two layers, like that, for instance, of orificial mucosa, is not 
specific for psoriasis. It is the substratum of many forms of des- 
quamation especially of the psoriasiform type; it is observed, for 
example, in the dermatitides, in recent cicatrices, after the spongiosis 
of eczema and the eczematides, in the psoriatiform syphilides, etc. 

In psoriasis itself, it is apparently only secondary. The investi- 
gations of Munro (1898) and of Sabouraud, confirmed by those of 
Paul Haslund (1913) have shown that aside from the lesions of the 



108 ERYTHEMATOSQUAMOUS DERMATOSES 

stationary stage which I have described, small miliary abscesses 
containing leukocytes but without demonstrable microbes, may be 
observed in incipient or progressing psoriasis; these minute abscesses 
form in the subcorneal layer of the rete and are successively pushed 
up into the horny layer where they appear as a layer of desiccated 
cells. When the eruption is actively progressing, they are very 
numerous and succeed one another rapidly and incessantly at the 
same point or at neighboring points. This lesion is considered by 
Sabouraud as pathognomonic of psoriasis and, reasoning on these 
premises, he groups under the heading of psoriasis more than half 
of the seborrhoids or eczematides. The minute abscesses of psoriasis 
actually bear a close resemblance to the small foci of spongiosis 
which I have emphasized in the eczematides; when the two forms of 
microscopic lesions are confused, the histological differentiation 
becomes very difficult and in certain cases must rest on a single 
characteristic, namely the extreme paucity of microbes taking stains 
in sections of psoriasis, whereas there is an abundance of organisms 
in the eczematides. 

Etiology and Character. — Psoriasis occurs in all countries and 
climates, somewhat more frequently in men. It may appear at 
any age, from two to eighty years, but is most common around the 
period of puberty and during adolescence. [It constitutes from 3 to 
5 per cent, of all cases seen in dermatological practice.] Psoriasis is 
not contagious. It seems to be hereditary, or familial, in one- 
fifteenth to one-twentieth of the cases. 

In favor of its external parasitic origin have been urged the sharp 
limitation and the centrifugal development of its lesions; its occur- 
rence, in psoriatics, in localities traumatized by vaccination, tattoo- 
ing, friction of suspenders or other tight articles of clothing, scratches 
made with a pin; a feature as a matter of fact which suggests auto- 
inoculation. Destot (Lyons) is said to have successfully inoculated 
himself with psoriasis, but his experiment does not appear convincing. 
Arguments may also be based on the therapeutic action of parasi- 
ticidal topical applications. But the direct examination of the 
minute abscesses invariably shows them to be free from microbes 
and in the scales the common microbes are extremely rare. In the 
studies on the etiology of psoriasis directed by J. F. Schamberg 
(1913) no special microorganism in the skin or the blood of psoriatics 
was found. The parasitic theory, although reasonable, is by no 
means proved. 

The relations of psoriasis with arthritism and with the dyscrasias 
rest on a few facts, but are neither accurate nor demonstrable. To 
describe a tendency to psoriasis as herpetism, is merely a play on 
words. 

Too rich a diet, especially in albuminoid substances, seems to be 



PSORIASIS 109 

capable of favoring the first appearance, or at any rate the eruptive 
outbreaks, of psoriasis. 

The theory of the nervous origin of psoriasis is supported by the 
usual symmetry of the eruption, its occasional appearance in con- 
nection with a serious accident or emotional shock, the coexistence 
of neuralgias and arthropathies. It has been claimed by several 
observers that psoriasis manifested itself relatively often in the 
participants of the late war. If this be true (which is doubtful), 
a number of other causes besides emotion might be involved (too 
much meat, etc.) 

Of recent years, several authors have advanced the view of a 
possible connection between psoriasis, or certain forms of psoriasis, 
and attenuated tuberculosis. Although it is certain that the arthrop- 
athies of psoriasis present marked analogies with the tuberculous 
rheumatism of Poncet, the great majority of psoriatics do not 
convey the impression of being the subjects of tuberculosis. Psoriasis 
and tuberculosis are so common, moreover, that there is nothing 
remarkable about their frequent coincidence. Brocq groups 
psoriasis under his "cutaneous reactions," and admits that it may 
develop under the influence of a number of occasional causes, or 
without this influence through the effect of disturbances of the 
general conditions not yet determined by chemical analysis. These 
indefinite phrases aptly express our ignorance concerning the true 
character of this dermatosis. 

Treatment. — This must be in the first place external and local. 
It comprises two stages: 

1. Cleansing. — It is indispensable to clean and free the patches 
from their scaly covering before the medicinal agents are made to 
act upon them. This is accomplished by more or less prolonged 
soapy, alkaline, or tar baths, or steam baths, or by moist or rubber- 
ized dressings. In most cases vaseline or glycerol inunctions, soft 
soap, lard, etc., are used. Salicylated vaseline (5 per cent.) with 
applications of green soap twice daily, seems to be the most rapid 
procedure; at the end of a few days, we may pass on to other 
remedies. 

2. Reducing Agents. — All reducing agents (see Therapeutic 
Notes) are capable of healing the patches of psoriasis. Treatment is 
begun with the weakest, with the tars, especially oil of cade the 
virtues of which have long been tried, in the form of salves, glycerol- 
ated, or in the pure state. More or less deodorized and decolor- 
ized extracts have been prepared, known as lenicade, oxycade, etc., 
which are liked by patients [but are less effective]. 

The mercurials (calomel, turpeth mineral, etc.) or sulphur, etc., 
are reserved for the scalp and the face. The addition of salicylic 
acid (1 per cent.) increases their action. It must be kept in mind 



110 ER Y THE MA TO-SQ UA MO US DERMA TOSES 

that a mixture of sulphur and a mercurial salt would dye the hair 
and the same remark applies to naphthol. 

Strong reducing agents, or salves containing such agents, which 
are efficient but irritating should not he employed except in rather 
scanty eruptions and when the patient can be watched. 

Chrysarobin is the best; it is employed as an ointment with 
ichthyol, or preferably as a varnish with traumaticine. It acts only 
when an erythema is produced, which however, must remain 
moderate. Alkaline baths and washes must be avoided during its 
use. It stains the hair and linen a violet color and sometimes gives 
rise to severe conjunctivitis. But it will sometimes bleach a case 
of psoriasis in a fortnight. 

Pyrogallic acid, in salves, varnishes, or in ethereal solutions, will 
destroy the linen and blacken the epidermis and the hair; it is very 
efficacious but difficult to handle on account of the danger of poison- 
ing when it is employed on large surfaces. 

Of the innumerable chemical products extolled abroad as anti- 
psoriatics, none seems to me worthy of being retained. 

Radiotherapy — the indications of which in psoriasis I pointed 
out in 1898— may rapidly obliterate recent or even inveterate 
patches which have first been cleansed. It is only applicable, 
however, in circumscribed eruptions, and does not prevent recur- 
rences. It is employed only in exceptional cases. 

3. General Treatment. — This is much less important. Arsenic 
has been regarded as a specific and administered in all its forms; 
moderate doses are often beneficial; energetic arsenical medication 
subjects the patient to the risk of intense pigmentation and may 
produce a genuine leuko-melanodermia. The arsenobenzols are free 
from this drawback and are sometimes very successful but must be 
handled very cautiously. 

Potassium iodide, in enormous doses from 15 to 25 grams daily has 
been advocated; I have obtained no results from it. Injections of 
calomel, or of yellow oxide, by themselves alone have sufficed to 
cure some cases of typical psoriasis and to improve markedly 
arthropathic psoriasis; unfortunately they are not reliable. Experi- 
ments are now under way with injections of sulphur in solution. 

It goes without saying that proper hygienic measures should be 
recommended with abstinence from alcohol and stimulants. Schain- 
berg and his associates (Philadelphia Research Laboratories) have 
emphasized a habitual nitrogen retention in these cases and the 
favorable influence of a vegetable diet poor in nitrogen, as pre- 
viously recommended by Bulkley, Besnier and others. 

Warm mineral springs and sulphur waters are useful in some 
cases. 



PARAPSORIASIS 



111 



PARAPSORIASIS. 

Under this provisional name, Brocq in 1902 grouped several rare 
and unclassifiable dermatological types, characterized by non- 
pruriginous erythemato-squamous spots, extremely persistent and 
rebellious to all treatment. 

It is exclusively the objective appearance of these dermatoses 
which led to their mutual approximation to psoriasis. Their origin 
and character are unknown, hardly even surmised, and probably 
variable. 

Three types are distinguished: 

Parapsoriasis Guttata. — This eruption is disseminated over the 
trunk and limbs in faintly pink or brownish-red lenticular spots, 
very slightly infiltrated, covered with dry adherent scales, com- 
parable to a sealing wafer. Scratching of these spots gives rise to 
fine purpuric puncta. The eruption resembles an abortive guttate 
psoriasis, or a resolving papulo-squamous syphilide. It is main- 
tained by the appearance of new lesions, originating separately or 
in crops. 




Fig. 24. — Lichenoid parapsoriasis dating back four years, in a man aged thirty-two 

years. 



Parapsoriasis Lichenoides. — This type differs from the preced- 
ing by the more papular, more infiltrated and less psoriatiform 



112 



ER J ' THEM A TO-SQ UA MO US DERMA TOSES 



character of the lesions. These appear in the form of bright pink, 
hemispherical or flattened, glistening and non-scaly papules; later 
on, the lesion becomes purplish and bears a scale which seems to be 
imbedded in a depression of the papule; finally there remains only 
a yellowish macule with slight atrophy of the epidermis. The erup- 
tion is scattered over the trunk and the limbs or is arranged in 
clusters and network; it is not at all pruritic. The reproduction of 
the lesions during years in the same regions gives the skin a pecu- 
liarly mottled appearance (Fig. 24). The differential diagnosis 
must be made from lichen scrofulosum and other tuberculides, 
lichen planus, syphilides and psoriasis. The cases published by 
Unna [and Pollitzer], Jadassohn, Xeisser, Pinkus, Crocker, etc., 
under the names of parakeratosis variegata, lichen psoriasis, pity- 
riasis lichenoides chronica, etc., belong to the first two forms. 




25. — Parapsoriasis in patches of thirty years' standing on the flank of a man, 
aged forty-seven years. 



Parapsoriasis in Plaques. —It consists of circumscribed spots or 
patches of a yellowish pink or wine color, with few or no scales, non- 
infiltrated and oon-pruritic; their configuration is round, oval, zoni- 
i'oini, annular or reticulate (Fig. 25); their arrangement varies 
slightly from year to year; on their surface the texture of the skin 
is modified and the normal mosaic more marked. The eruption 
occupies the trunk and the limbs. It resembles the eczematides, 



PSORIATIFORM SYPHILIDES 113 

premycotic plaques, or tertiary syphilitic erythemas. This type 
was described in 1897 by Brocq, and later by J. C. White, under the 
name of pityriasic erythroderma in disseminated patches. Crocker 
gave this form the name of xantho-erythroderma perstans. 

The histology of parapsoriasis, very carefully studied by Civatte, 
presents briefly the following lesions : Edema and congestion of the 
papillary body, with perivascular cuffs consisting especially of lym- 
phocytes, sometimes collections suggestive of lichen scrofulosum; a 
rather atrophic Malpighian layer with small areas of parakeratosis. 

Parapsoriasis appears at all ages, especially during youth and 
maturity, its duration is indefinite; the lesions disappear, while 
others insidiously supervene. Its nature is unknown; in some of the 
cases the patients were old syphilitics; on the other hand, the theory 
maintained by Civatte, according to which the disease is a tuber- 
culide, is based on strong clinical and pathologico-anatomical argu- 
ments. 

All local medication is ineffectual ; injections of arsenical prepara- 
tions and of mercury have seemed to me useful in some cases. 

PSORIATIFORM SYPHILIDES. 

Strictly speaking erythemato-squamous syphilides do not exist. 
However, as it is always in connection with syphilis that the question 
of the diagnosis of pityriasis rosea, psoriasis, etc., arises, and as 
errors are frequent, I believe the insertion of the following para- 
graph will be useful. 

In the first place, let me point out that syphilitic roseola is 
never squamous or scaly (A. Fournier), whereas, pityriasis rosea and 
psoriasis are always scaly. 

As to the papular syphilides of secondary lues, these are habitually 
slightly scaly, but may become so to a degree which entitles them to 
the epithet of psoriatiform. 

Their dimensions are miliary, lenticular, or nummular; their 
form is round, orbicular, sometimes annular in certain regions; 
their color is pink or red, but often dull, purplish, not so vivid as 
the lesions of psoriasis. Although desquamation may be profuse, 
it is nevertheless not so abundant as in psoriasis; scratching reveals 
no subcorneal pellicle and very readily produces traumatic purpura. 

But the sign par excellence of the syphilides, on which the diagnosis 
must always rest, is their firm resistant infiltration, their hardened, 
neoplastic consistence; they have substance, according to an 
expression used by A. Fournier. The lesions of recent psoriasis, 
on the contrary, are pliable and not indurated. All this signifies 
that in spite of their apparent anology, syphilis really produces 
squamous papules, whereas psoriasis gives rise to squamous macules. 

The eruption of psoriatiform syphilides is irregularly scattered 



114 ERYTHEMATO-SQUAMOUS DERMATOSES 

everywhere, often confluent on the face, the back, the nape of the 
neck; no patches are found on the elbows, knees and scalp. The 
eruption is more or less polymorphous, not all the lesions are 
psoriatif orm ; finally, there are coincident glandular swellings or 
adenopathies, mucous patches, etc.; briefly, signs of syphilis, and the 
Wasserniann reaction is positive. 

The tubercular syphilides of tertiary lues may be abundantly 
squamous and psoriatif orm. However, they are firm to the touch, 
usually circinate, always segregated, regional, not very numerous. 
Moreover, healing is followed by cicatrices. 

ERYTHEMATO-SQUAMOUS EPIDERMO-MYCOSES. 

Several parasitic cutaneous diseases, due to vegetable parasites, 
may assume the form of red and squamous spots. 

This is rarely the case in pityriasis versicolor; its spots are yellow- 
ish or brownish; exceptionally they may be of a pink color. It is 
noteworthy that one of the peculiarities of microsporon furfur is that 
it produces practically no congestive or inflammatory reaction. 

Erythrasma. — This affection on the contrary often leads to con- 
fusion, especially with the pityriasiform eczematides in large patches. 
It is distinguished by the dryness of its scales, by its localization, 
by its persistence, by the almost complete absence of pruritus, and 
especially by the presence of the microsporon minutissimum in 
large numbers in the epidermis (p. 532). 

Trichophytosis of the Smooth Skin.— This is characterized by the 
generally perfect orbicularity of the red and squamous spots, by 
their relatively rapid and regular peripheral development, by the 
rather frequent presence, especially on their borders, of vesicles which 
have earned for this affection the name of herpes circinatus (p. 522). 

Epidermophytosis. — The rapidly extensive, red and squamous 
spots, with polycyclic contours, bordered by small vesicles or a 
scaly margin, which develop in the groin and in the large cuta- 
neous folds, constituting the eczema marginatum of Ilebra, are due 
to the epidermophyton inguinale; the microscope readily reveals 
the mycelium of the parasite in the scales (p. 524). 

Microsporosis. Various microsporons may vegetate on the 
hairless skin; the spots caused by them are of irregular form, 
indistinctly outlined, more pityriasic than erythematous and very 
readily curable (p. 527). 

Favus Cutaneus. — This may appear without "cups" in the form 
of red and squamous, rarely vesicular, distinctly outlined and fairly 
regular rounded spots (favus herpeticus) ; the achorion is abundantly 
represented in the scales. 

Tropical Epidermomycoses— These are discussed elsewhere in 
this book (p. 528). 



CHAPTER VI. 
ERYTHRODERMAS. 

The name erythroderma is applied to a very extensive or general- 
ized, persistent and squamous inflammatory reddening of the skin. 

The symptom of extensive and persistent redness is very easily 
demonstrable; but as it occurs under very different pathological 
conditions, its significance and value vary to a high degree. 

The redness of erythroderma is inflammatory, so that very exten- 
sive vascular nevi, for example, do not belong under this heading. 
The vascular congestion is sometimes accompanied by a certain 
degree of swelling or retraction of the tissues ; the skin feels warm 
to the touch, but the patients frequently complain of a constant cold 
sensation. 

The redness is very extensive; however, the erythrodermas are 
practically limited in degree to the chronic erythemas and the 
erythemato-squamous dermatoses. 

It is persistent. The meaning of this word is somewhat elastic; 
usually, to be declared as erythrodermic, the duration of a red 
eruption must exceed seven days. 

Finally, and especially, the erythrodermas are squamous from the 
start or after a few days, very abundantly or scantily, under variable 
forms, powdery, furfuraceous, lamellar or exfoliating, etc. The 
epithet exfoliating or exfoliative applies to a considerable number of 
the most characteristic types; other cases have been designated 
under the name of pityriasis rubra. 

The term "pityriasis" according to Besnier, is a simple dermo- 
graphic expression specifying a particular form of epidermic des- 
quamation in lamella? as fine as bran, or furfuraceous. It is a 
traditional designation, not indicative of any relationship between 
them, for cutaneous affections differing as widely as pityriasis 
simplex, pityriasis versicolor, pityriasis rosea of Gibert, pityriasis 
rubra pilaris. The common denomination "pityriasis rubra" 
therefore does not apply to all erythrodermas and is reserved in 
this book for the variety described by Hebra. 

The symptom of erythroderma is met with under four different 
conditions: (1) As a constituent of peculiar eruptions developing 
on the healthy skin; these are the Primary Erythrodermas. (2) 
Through the effect of generalization of one of the dermatoses with 



116 ERYTHRODERMAS 

red and squamous spots, described in Chapter V; for this group 
I reserve the name of Erythrodermic Dermatoses. (3) As a compli- 
cation of a preexisting eruption; these arc the Secondary Erythro- 
dermas. (4) Finally, there occur Congenital Erythroderma* and 
cases developing in newborn infants. 

I. PRIMARY ERYTHRODERMAS. 

Acute forms have been described, lasting a few weeks; subacute 
forms, lasting several months; and chronic forms, lasting a year or 
longer. 

This subdivision, although convenient for the grouping of obser- 
vations, implies neither difference nor identity of character among 
these clinical forms. 

. 1 . Primary Acute Erythroderma. — This is a generalized erythema 
with a foliaceous desquamation, of toxic or infectious origin, also 
known under the name of Recurrent desquamative scarlatiniform 
erythema ( Fereol and E. Besnier) and Acute benign exfoliating 
dermatitis- (Brocq). 

After two or three days of prodromata, in the form of prostration, 
headache, chills, and fever of 38° or 39° [100° to 102°] the eruption 
makes its appearance as a red pruritic surface in the large folds of 
the trunk and the limbs; it becomes generalized in a few days, the 
head sometimes escaping. 

Before the redness disappears, desquamation begins and gradually 
extends; it is locally furfuraceous but more apt to occur in large 
collodium-like shreds or on the hands and feet, in the form of an 
incomplete glove or sandal (Fig. 20). The skin underneath appears 
smooth, sometimes still scaly, or oozing in the folds. The mucous 
membranes may be affected; redness of the conjunctiva 3 , an ery- 
thematous angina and desquamation of the tongue are noted. 
The genera] condition becomes practically normal long before the 
end of the cutaneous disease, which lasts about three weeks. The 
nails remain marked by a transverse furrow; loss of hair is incon- 
siderable. Relapses are frequent, at intervals of months or years, 
but usually dimmish in severity. 

The causes of this eruption are imperfectly understood. A neces- 
sary predisposition and various causative factors are admitted. 
First in order come the intoxications, notably mercury, the influence 
of which should be looked for in all its forms: internal, external, 
medicinal and accidental; picric acid, quinine, chloral, belladonna, 
opium, may also be responsible. When toxiderma can be excluded, 
infections are to be thought of, such as gonorrhea, malaria, strepto- 
coccus infection, etc 

The differential diagnosis must be made from the scarlatinoid 



PRIMARY ERYTHRODERMAS 



117 



erythemas, which are less extensive, more transitory and less 
desquamative ; and especially from scarlet fever which is not recur- 
rent, is accompanied by angina and more pronounced general 
phenomena and has a more belated desquamation. [The most 
important differential feature is found in the circumstance that the 
exfoliation usually begins while the erythema is still pronounced; 
but a diagnosis is often impossible and] in doubtful cases the same 
prophylactic measures are called for as in the presence of scarlatina. 




Fig. 26. — Acute primary erythroderma in the stage of desquamation following 
ingestion of a mixture containing opium (Berge's case, Soc. Med. des Hop., February 
22, 1907). 



B. Primary Subacute Erythroderma. — This probably represents 
merely a more prolonged and more serious form of the preceding 
type; it is also known as generalized exfoliative or exfoliating derma- 
titis of Wilson- Brocq. 

The onset is the same, with or without prodromata; generaliza- 
tion is complete, somewhat more gradually established; the folia- 
ceous desquamation is so active that handfuls of epidermal shreds 
may be gathered up in the morning from the patient's bed. The 
mucous membranes and the appendages are always involved; the 
nails and nearly all hairs of the body may fall out toward the end 
of the third to fourth week. 

The tension of the skin, the constant sensation of cold, the loss of 1 
weight notwithstanding the good appetite, the diarrhea, the great 



118 



ERYTHRODERMAS 



diminution in nitrogen excretion and the hectic fever indicate the 
gravity of the disease. Death occurs from cachexia or as the result 
of complications, in one-sixth of the cases. The duration is from 
three months to a year. 

This rather uncommon subacute form is observed in adults, 
especially in inebriates and in connection with some form of intoxi- 
cation or auto-intoxication. Relapses hardly ever occur. 

( '. Primary Chronic Erythrodermias. At the present writing, three 
types can be differentiated. 




ititis of three years' standing, in a man aged 



1 . The Chronic Form of the Exfoliative Dermatitis of Wilson-Brocq. — 
Under this heading are grouped the cases analogous to primary 
subacute erythroderma but lasting several years (Fig. 27). 

2. Pityriasis Rubra of Hebra-Jadassohn. The erythema begins in 
various regions, especially in the large folds, as red surface lesions 
with furfuraceous scales, without infiltration or oozing. The 
complete generalization takes place in a few months, at most two 
years; chills are common and itching is variable. 



PRIMARY ERYTHRODERMAS 119 

The skin gradually becomes thickened, then atrophied and 
retracted to the point of interfering with movements. The appen- 
dages fall out. Death supervenes at the end of a few years, in 
a state of general marasmus and according to Jadassohn almost 
invariably through tuberculosis. Since his investigations (1892) 
there is a tendency to group pityriasis rubra under the heading of 
the Tuberculides. 

Cases of partial eruption have been reported, as well as subacute 
benign cases, the interpretation of which is doubtful. 

3. Premycotic and Leukemic Erythrodermas. — In male adults, the 
onset of an erythroderma has been observed beginning with highly 
pruritic red spots, becoming universal, scarlatinoid, more purplish 
in the folds and dependent portions, sometimes with depressed 
white spots scattered here and there. Desquamation is usually very 
slight or it may be dry and lamellar. Febrile attacks may occur. 
The nails usually remain intact, but the hairs fall out to a great 
extent. 

Three constant features attract attention : a frenzied irrepressible 
pruritus, causing the nails to become worn off, edematous thickening 
of the skin, which forms ridges toward the great folds and generalized 
glandular swelling. 

After a very long time, up to ten years or more, small cutaneous 
nodosities may make their appearance, having the structure of 
mycosis fungoides (p. 659) . 

This premycotic erythroderma, pointed out by Besnier and 
Hallopeau, may present prolonged remissions; it may also lead to 
death from cachexia before the apperance of tumors. 

The lymphoderma pemiciosa of Kaposi was probably an erythro- 
derma of this kind, which became complicated by leukemia (p. 655). 

The leukemic erythroderma studied by Audry, Nicolau, and others, 
is a pathological type closely related to the preceding. Desquama- 
tion is perhaps more profuse and pruritus less severe ; but especially, 
in addition to the adenopathy, there is hypertrophy of the spleen 
and a relative or absolute leukemia. Sometimes, the appearance 
of small nodules in the skin, or papillomatous patches, has been 
noted. Death is inevitable and may supervene in less than two years. 

All cases of primary chronic erythroderma necessitate, from the 
diagnostic and prognostic point of view, thorough clinical study with 
careful examination of the viscera and glands, complete and repeated 
examinations of the blood and sections of the skin and the glands, 
for histological and bacteriological examination as well as animal 
inoculation. Only in this way can we hope to determine the rela- 
tions of pityriasis rubra and mycosis fungoides with the leukemias, 
pseudoleukemias, tuberculosis, etc. 



120 ERYTHRODERMAS 

n. ERYTHRODERMIC DERMATOSES. 

Sonic of the great dermatoses may become erythrodermic through 
generalization in the course of their evolution. In these cases, the 
characteristics of the eruption persist, only modified by the extension 
it lias undergone. 

Generalized Eczema. -Generalized eczema proceeds in successive 
relays, invading new territories and becomes permanently estab- 
lished if the conditions of eczematosis exist in the patient; but it 
rarely becomes universal. Even in these cases it retains its tendency 
to recrudescences, paroxysms, oozing, to a reddened appearance and 
severe itching. The mucous membranes remain intact and the 
appendages are only gradually affected. The general condition is 
far from being as seriously affected as in the cases of true erythro- 
derma, whether primary or secondary. 

The principal difficulty is the recognition of the nature of this 
eczema, whether it is primary, or secondary to a prurigo, for instance, 
;u id on the other hand to discover the nutritional disturbances, 
internal suppuration or visceral lesion of which it is often a mani- 
festation, such as nephritis, cancer, etc. The treatment is not very 
effective and must be very cautiously handled. 

In generalized eczematide— pityriasis rubra seborrhceica of Unna, 
or malignant exfoliating form of seborrheal eczema — the eruption 
extends little by little but is rarely universal. The eruptive areas 
or widely invaded regions are sometimes red and dry, covered with 
pityriasis- fatty scales, sometimes oozing and covered with yellowish 
scaly, not very adherent crusts, the contours are rounded or 
polycyclic (see Fig. 18, abdominal region); in the folds and under 
i he thick crusts, serous or purulent oozing is present in all cases. 

It is often difficult, until a few days or weeks of treatment have 
elapsed, to distinguish between a generalized eczematide, a primary 
or secondary eczema and an eczematized psoriasis. The rounded 
crusts may even suggest pemphigus. The general condition usually 
remains favorable. The prognosis is less gloomy than that of the 
other generalized dermatoses and especially that of exfoliating 
berpetide (p. 122). It depends upon the degree of toleration of the 
skin for the topical reducing agents which must here be employed 
with moderation. 

Psoriasis universalis may finally become absolute and total; the 
redness is uniform from head to foot; the desquamation loses its 
stratified and micaceous character, except at the seats of pre- 
dilection; neither oozing, nor crusts, nor pruritus is present. The 
hairs of the seal]) and body become scanty; the nails are striated 
and ridged. Arthropathies may develop. 

The course, without paroxysms, is of an absolutely chronic 



SECONDARY ERYTHRODERMAS 121 

character. Treatment often remains completely ineffective ; although 
I have obtained nearly complete but always temporary cures by 
means of mercurial injections, using calomel or the yellow oxide. 
The arsenobenzols might be given a trial. 

Pityriasis rubra pilaris may exceptionally, at the onset or in 
consequence of its progressive extension, present an erythrodermic 
appearance. But healthy skin areas can always be demonstrated, 
in distinctly outlined, sometimes angular islands as well as peripilar 
cones on the borders of the surface lesions or at the points of election. 
The desquamation is plaster-like and adherent. 

Acute lichen planus, sometimes spreads over large surfaces and 
may assume an erythrodermic appearance; this abnormal exten- 
sion is usually initial and rapidly retrogressive. It soon becomes 
possible to discover the characteristic papules, if necessary with the 
assistance of a lens on the red surfaces themselves or at their borders. 

Pemphigus foliaceus occasionally presents to a high degree the 
clinical appearance of an abundantly exfoliating erythroderma. 
The disease has generally passed at the onset through a stage of 
bullous eruption and sometimes bullous lesions can be found 
around the erythrodermic areas. The exfoliation of pemphigus 
foliaceus is noteworthy for the moist or even oozing condition of the 
tissues underneath the scales. 

Equine scabies is a very rare disease which may appear under the 
guise of erythroderma, as illustrated by the case of Besnier's and a 
personal observation of my own. The redness is universal, involving 
even the face and the scalp; the crusted or powdery scales predomin- 
ate on the hands and feet; itching is not excessive. No burrows 
can be detected; but even the smallest scale is seen under the 
microscope to teem with the parasite (sarcoptes) in all its stages. 

m. SECONDARY ERYTHRODERMAS. 

. Generalization, as has been seen, leads to the so-called " erythro- 
dermic" appearance in the great dermatoses which have just been 
briefly reviewed. On the other hand, their course may be tempor- 
arily arrested by, or it may terminate in a very extensive or even 
universal exfoliating dermatitis; this marks and transforms the 
characteristics of the first eruption and seems to take its place, 
reproducing the aspect and behavior of a primary erythroderma. 

In the first case, there has been an extension with more or less 
complete preservation of the characteristics belonging to the first 
eruption; the second case, where there is unification of the patho- 
logical picture, was interpreted by the older authors as a transfor- 
mation, whereas modern writers are inclined to see in it the effect of 
a complication. 



122 ERYTHRODERMAS 

It is readily understood that an investigation of the patient's 
antecedents and preliminary condition is usually required in order 
to establish the fact that the erythroderma is really secondary and 
the nature of the dermatosis on the soil of which it has developed. 

The secondary erythrodermas manifest themselves under two 
forms, ordinarily designated by the traditional names of benign 
herpetide and malignant herpetide. 

Benign Form (episodic erythrodermas of Besnier). — The 
erythrodermie complication may be partial, regional or very exten- 
sive; rarely is it total; it is always transitory, lasting a few days to a 
few weeks. There are valid reasons for ascribing it to the inoppor- 
tune or badly tolerated intervention of an external medicinal agent, 
such as a mercurial preparation, chrysarobin, picric acid, etc., or of 
some internal medication. Relapses are extremely liable to occur. 

Malignant Form (exfoliative herpetide of Bazin, chronic malig- 
nant exfoliative dermatitis of Vidal and Leloir). — By Bazin, 
who described it, exfoliative herpetide was interpreted as the 
common outcome of certain eczemas, psoriasis, pityriasis; super- 
vening by imperceptible transition and representing a sort of cachexia 
of the skin, comparable to asystoly in heart disease. 

The symptoms are those of the subacute form of primary erythro- 
derma, but with less fever; there is, however, well-marked general 
exhaustion and marasmus. The elimination of urea in the urine, 
always greatly diminished, may be reduced to 10 or even 4 grams 
per day; on the other hand, up to 10 grams of urea have been found 
in the daily scales. 

The prognosis is fatal although more or less prolonged remissions 
have been observed. 

There is a tendency to attribute this " malignant herpetide" to a 
toxic, infectious or autotoxic complication of the same character 
as that which gives rise to the primary erythrodermas. 

IV. CONGENITAL ERYTHRODERMAS AND ERYTHRODERMAS 
OF THE NEWBORN. 

In little children, various types of congenital or acquired, tempo- 
rary or persistent exfoliative erythrodermas have been observed. 
The following cases must be distinguished : 

1 . Lamellar Desquamation in the Newborn. — This represents an 
exaggeration of the phenomenon of physiological desquamation 
seen in many newborn infants and consists of desiccation and 
splitting of the epidermis in the first days of life, followed by the 
shedding of this epidermis, furfuraceous or in shreds, from the third 
to fifth day up to the thirtieth or sixtieth, according to Parrot. 

In rare cases, such as that observed by Grass and Torok (1S95), 



ERYTHRODERMAS OF THE NEWBORN 



123 



the child is bom with a sort of supra-epithelial collodium-like layer 
(epitrichium) ; this splits after the first hour and in a few days 
becomes detached in the form of large shreds ; the skin then becomes 
normal again. 

2. Exfoliative Dermatitis of Nurslings. — Described by Ritter von 
Rittersheim (1878) begins during the first to fifth week of life, around 
the mouth or, more rarely, in other parts of the body; it becomes 
rapidly generalized over the entire integument and finally extends 
to the extremities. The skin is of a purplish-red color and is des- 
quamated in large dry shreds. Bulla? have sometimes been observed. 
Certain authors believe that this affection is related to epidemic 
pemphigus. As a rule, the disease is febrile and in one-half of the 
cases it leads to death, often within a week. 



Jf 


... j 111 


wL 




.. 


^^^^^ .JrtM 


'■■' • . * ■ ".' 


\ JssHaaHBM 



Fig. 28. — Erythroderma in a newborn infant (generalized eczematide.) 



3. Generalized Dermatoses. — Various generalized dermatoses, in- 
cluding medicinal, mercurial and other eruptions, are encountered 
in children. 

I have published a case of seborrheal eczema or eczematide in an 



1 24 ERYTHRODERMAS 

otherwise healthy child of five weeks ( Fig. 28); onset at the ear. 
almost total generalization in nine days; scarlatinoid redness with 
dry scales or greasy crusts, in different localities; recovery in 
three weeks. 

Desquamative Erythroderma of Nurslings, described l>y ('. Leiner 
in 1907, is a morphologically analogous morbid type. He was 
enabled to observe 43 cases, usually beginning on the scalp, 
with 1") deaths. Beck's record of 16 personal cases, in which the 
disease usually began on the buttocks, confirms the observation 
that this grave eruption, which seems to be of toxic character, is 
peculiar to breast-fed children suffering from enteritis. A change of 
alimentation is urgently required. 

4. Diffuse Congenital Hyperkeratosis. — Also known as congenital 
or fetal ichthyosis, or ichthyosis sebacea (Kaposi), is a cutaneous 
malformation of which several degrees are known: 

The severe type (diffuse congenital malignant keratoma) [harlequin 
fetus] \> incompatible with life. The infant, born at term or pre- 
maturely, presents a dreadful appearance; its entire skin is red 
and tense, as if too tight, fissured, covered with large yellowish 
layers or crusts several millimeters thick, apparently resulting from 
the desiccation of a sebaceous coating. The face is formless; move- 
ments of the limbs are almost impossible; the child is unable to 
suckle and promptly succumbs to cold. 

The benign type (generalized ichthyosiform hyperkeratosis) is not 
■fatal; it is usually confused with ichthyosis. It will be discovered 
in the chapter on the Keratoses (p. 203). 

Pathological Anatomy of the Erythrodermas. — The lesions of all 
erythrodermas are associated with vascular congestion, a variable 
cellular infiltration in the papillary body, with more or less edema 
and pigmentation and corneal exfoliation, the mechanism of which 
usually remains obscure. 

Reliable histological investigations are not numerous and have 
yielded divergent results in forms bearing the same label. At the 
present writing a differential histological diagnosis between the 
various types is out of the question. The following are the few 
available data on this subject: 

In the primary subacute erythrodermas there is claimed to be 
parakeratosis, intrapapillary infiltration with enlargement of the 
papillae. Central, ganglionic and peripheral nervous lesions have 
been described by Mario Oro. 

In the pityriasis rubra of Hebra the papillary body, at first 
infiltrated, later on undergoes atrophic changes; the glands and 
follicles disappear; the stratum granulosum is diminished or absent. 
In a very remarkable case Brunsgaard found in sections of the skin 
typical tubercles with giant cells and Koch's bacilli. It had already 



ERYTHRODERMAS OF THE NEWBORN 



125 



been shown by Jadassohn that in autopsies on cases of pityriasis 
rubra, tuberculosis was found in various organs in seven out of 
eight cases. 

Premycotic erythroderma represents the most distinctive ana- 
tomical type. The illustration gives a fairly accurate idea of the 
condition (Fig. 29). 




Fig. 29. — Histology of premycotic erythroderma. The dominant lesion con- 
sists of a very dense cellular infiltration (F) , occupying the papillary body and 
having a sharp lower boundary; it is composed of lymphoid cells arranged in an 
adenoid network. The afferent vessels of the chorion (G) are surrounded by cellular 
cuffs. The papillse (E) are enlarged and elongated. The interpapillary buds (A) 
are drawn out and often bifid. The horny layer (B) is thick and desquamating. 
Parakeratosis is noted in places (C). In the rete may be seen minute cellular nests 
(£)) filled with lymphocytes; those are inconstant, but possess great diagnostic value, 
being specific of mycosis fungoides. X 65. 



In the malignant exfoliative herpetides there exist parakeratosis, 
according to Leloir, and a destructive change of the connective- 
tissue fibers, especially around the vessels, with preservation of the 
elastic fibers. These lesions, which were reported as characteristic, 
could not be confirmed by Mario Oro. 

The generalized dermatoses preserve the histological lesions 
peculiar to them, although with some modifications. 

Treatment of the Erythrodermas. — The most essential requirement 
is to ascertain with great care the possible cause of the erythroderma. 
When there is reason to suspect an intoxication, or some external 
agent, this injurious factor must, of course, be removed. An 
existing auto-intoxication should be controlled by dietetic measures, 
free ingestion of water, enteroclysis, injections of glucose or other 
sera, together with general hygiene. With special reference to 



126 ERYTHRODERMAS 

mycosis fungoides and the leukemias and pseudoleukemias, radio- 
therapy is known to furnish a valuable method, if not for a cure at 
least for improvement and retardation of the course of the disease. 

Local Treatment must aim especially at non nocere. It comprises, 
depending on the case, prolonged or even permanent emollient 
baths, such as were formerly given abroad; moist aseptic dressings, 
or applications of oil and lime-water liniment, which are very 
troublesome to handle but afford a marked relief for the pruritus; 
finally, wrapping in cotton. It is often useful to cover the patient 
[thickly and continuously] with a bland powder between two sheets 
and to apply lotions only here and there or partial inunctions 
with a paste or a cream. Caoutchouc must be very cautiously 
employed; it will blanch certain erythrodermas, it is true, but 
seems to be capable of inducing very dangerous repercussions. 

All these topical agents are merely palliatives, aiming at the 
relief of the patient and the prevention of complications. They 
represent simply a marked form of expectant treatment. 



CHAPTER VII. 
PAPULES AND PAPULAR DERMATOSES. 

The eruptive lesions described as papules are small solid ele- 
vations which subside spontaneously. The terms of this definition 
may be stated with greater precision, as follows: 

The papules are circumscribed elevations of small dimensions; 
they have the size of a pin-head, a lentil or at most a large pea; they 
are always protuberant, but to a very variable degree. 

The papules are solid, which means that they do not contain an 
effused fluid; it is sometimes necessary to prick them with a needle 
in order to ascertain this fact. Finally, papules do not persist indefi- 
nitely, a feature which distinguishes them from small tumors of 
the same appearance; they disappear of their own accord, without 
leaving a scar, which differentiates them from tubercles; this is 
expressed in the statement that they undergo spontaneous resolution. 

Many papules develop exclusively at the site of the hair- 
follicles; these follicular papules will be discussed with the folliculoses 
(XIX). 

The papular prominence may become associated with various 
processes, for instance hemorrhage {papular purpura); vesicle form- 
ation in certain eczemas (papulo-vesicular eczema), and formation 
of pustules (papulo-necrotic tuberculides), etc. 

Very large papules are sometimes designated as papulo-tubercles. 

It sometimes happens that an infiltration similar to that which 
constitutes the papules, instead of being closely restricted to a very 
small surface, is spread out on the contrary in coin-shaped (num- 
mular) discs or in patches and becomes superimposed on an erythe- 
matous, erythemato-squamous, etc., process. In such cases, although 
these expressions are not, strictly speaking, correct, it is customary 
to employ the terms of papular plaques or patches. 

Anatomical Characteristics of the Papules. — The eruptive lesion 
known as a papule may be produced through different pathological 
processes. According as they affect chiefly the epidermis or the 
derma or the two tissues alike, a distinction is made between 
epidermic papules, dermic papules and mixed papules. 

Epidermic Papules.— Epidermic papules are most typically 
represented by the flat warts (Fig. 30) . In these, all the layers of the 
epidermis are hypertrophied, the mucous body (acanthosis) as well 



12S 



PAPULES AND PAPULAR DERMATOSES 



as the granular layer (granulosis) and the horny layer (keratosis). 
The papillae are elongated (papillomatosis) up to ten times their 
normal height. There is very little edematous or cellular infiltra- 
tion in the derma. 




y u'v 



■'■-r~'-.^ '- 



. KiRMAHSHI. 



Fig. 30. — Section of an epidermic papule. Flat wart of the face. A, keratosis; 
B, granulosis; C, acanthosis; D, papillomatosis. X 33. 

Iii the papule of prurigo, the rete mucosum especially is hyper- 
trophied, being three to four times thicker than normal; the con- 
dition of the horny layer and of the papillte is extremely variable. 

Dermic Papules. — Dermic papules are of two kinds depending 
on whether the substance which causes the prominence is an 
edematous fluid or an inflammatory cellular infiltrate. 




f^f^N 



i- -&.; 






Fig. 31. — Section of a dermic papule. Lenticular papular syphilide. X 25. 







The edematous papule is seen in urticaria and papular erythema; 
the local congestion and exudation of plasma between the meshes of 
the papillary body disappear in part, at the same time as the blood- 
pressure, in the cadaver and in excised segments; hardening of the 



MIXED PAPULES 129 

specimen in alcohol entirely obliterates the lesions. When the eryth- 
ema-papule is not purely urticarial, but more or less infiltrated, it 
is found to contain perivascular collections composed mainly of 
leukocytes. 

The most typical example of infiltrated papules is furnished by 
lenticular papular sypkilides (Fig. 31). The epidermis here is 
passively distended, thinned, sometimes with corneal exfoliation. 
The papillary body and the upper layer of the corium are the seat of 
a very abundant compact infiltration of cells, among which plasma 
cells predominate with a few giant cells ; at the periphery of the main 
focus the infiltration consists of perivascular cuffs of plasmocytes. 

The papule of lichen scrofulosorum is also essentially dermic; 
it is found to contain an infiltration of cells of various kinds, lym- 
phoid, epithelioid and giant cells, often arranged as tubercles, either 
in the papillary body or in the vicinity of pilo-sebaceous follicles. 

Mixed Papules. — In the mixed papules there exist combined 
epidermic and dermic lesions. The papule of lichen planus, which 
belongs to this type, consists of acanthosis, with more or less 
keratosis and a limited infiltration of the papillary body; the 
granular layer is hypertrophied here and there. 

The papule of strophulus has a thickened epidermis with localized 
spongiosis and an edematous infiltrated dermic base. 

Clinical Characteristics of the Papules. — A trained observer will 
have no special difficulty in the clinical distinction of the different 
varieties of papules. The epidermic hypertrophy manifests itself as a 
superficial, dry and hard, often yellowish prominence, which is in no 
way reducible on pressure. 

Edematous papules are pinkish-white, tense but compressible; 
they can be reduced by pressure with the finger-nail, but resume 
their shape after a few minutes. 

The dermic cellular infiltration produces a pink or red papule 
which is more profoundly indurated, resistant and elastic. 

The condition of the horny layer at the surface of the papule is of 
great importance, depending on the existing dermatosis; it may be 
thickened or stretched, desquamating in more or less friable and 
abundant lamellse or transformed into scales, crusts, and so forth. 

The differential diagnosis of papules in general is based upon 
their objective appearance and their course. In the first place, 
care must be taken not to confuse them with vesicles or pustules, 
which contain a fluid; with the tubercles of syphilis, leprosy, 
lupus or with tuberculides, which leave cicatrices; finally, with 
tumors of small dimensions, which are indefinitely persistent 
or progressive, such as: various nevi, sebaceous adenomas and 
hidradenomas, small cysts, circumscribed keratomas, epitheliomas, 
tumors of molluscum contagiosum, etc. 



130 PAPULES AND PAPULAR DERMATOSES 

In some cases a careful examination, pressure under a glass slide 
(vitropressure), expression of the contents, puncture with a needle 
or sometimes even the removal and examination of a piece of 
tissue for biopsy may be necessary. 

The following syndromes will be described in this chapter: 
Juvenile flat warts, which represent a special clinical variety of 
common warts. Lichen planus, with typical papular eruption, as 
well as its atypical varieties, which should be studied in this connec- 
tion, in spite of the irregular features assumed by the eruption; the 
papules of prurigo, as eruptive lesions, the disease as such being 
discussed in a separate chapter (XXIV); typical papular syphil- 
itic*; finally, the papular form of tuberculides known as lichen 
scrofulosorum. 

JUVENILE FLAT WARTS. 

The warts designated under this name appear as an eruption 
of small epidermic papules, not more than 3 mm. in diameter, flat- 
tened and barely protuberant; they have rounded or irregularly 
polygonal contours, are sharply circumscribed, have the color of the 
normal skin or show a yellowish, grayish or brownish tint; their 
surface is finely puckered or slightly scaly; they cause no itching. 

The warts are met with especially on the face, more particularly 
the cheeks, temples, forehead and chin, from a few up to several 
hundred in number. They may also occupy the back of the hands, 
associated or not with common warts, but are less frequent on the 
forearms. I have counted over 1500 on a young girl whose face, 
neck and even chest were dotted with them. 

These warts undoubtedly result from auto-inoculation or through 
transmission from other flat warts, probably also from common 
warts existing on the patient himself or in persons of his environ- 
ment. Children, young girls and young women are particularly 
susceptible. In men, they may be spread by means of the razor. 

After having multiplied and persisted for months or sometimes 
years, these flat warts finally disappear spontaneously without leav- 
ing ;i trace. 

The treatment must therefore aim especially at avoiding produc- 
tion of scars. Caustic agents must not be used. Tainting with an 
exfoliating mixture is usually prescribed (Therapeutic Notes, Sec- 
tion 5). Radiotherapy will cure flat warts with astonishing rapidity; 
a single session, with moderate dosage, is often sufficient. High- 
frequency sparks are likewise very successful. Jadassohn empha- 
sizes the efficacy of arsenic treatment. Suggestion probably plays 
a part in certain cures and the same remark is true for common 
warts. 



LICHEN PLANUS 



131 



LICHEN PLANUS. 

The term lichen was applied by Willan (and since his time) 
to dermatoses of different character. At the present time, the 
existence of a lichen " genus" comprising several species is no longer 
admissible. With the simple use of the term lichen, we now refer 
to the great and well defined dermatosis — also known as lichen 
planus, lichen ruber planus or Wilson's lichen — to be described in 
the following. 

The expressions: lichen simplex, lichen obtusus, lichen corneus, 
lichen scrofulosorum, will be defined further on. 




Fig. 32. — Lichen planus of the wrist and the palm of the hand. 

Symptoms. — The eruptive lesion of lichen planus is a typical 
papule, of the average dimensions of a pin-head, of polygonal flat- 
tened form, sometimes depressed or umbilicated; its surface is 
smooth and shining; its consistence is dry and firm; its color varies 
from a yellowish pink, which is the most common, to a dusky or 
purplish red; sometimes the color does not differ from that of the 
normal skin. 

These sufficiently characteristic features are often combined with 
another, which is pathognomonic : the presence of white or grayish 
opaline streaks and dots marking on the surface of the papules a 
network or nodular arborizations or stars on a pink background. 
The "sign of the net," the importance of which was emphasized by 
L, Wickham, is distinctly visible only on well-developed papules, 



i:;: 



PAPULES AST) PAPULAR DERMATOSES 



which may be isolated or grouped in patches; in order to demon- 
strate the net, it is advisable to moisten the papules with water, 
or paraffin oil, or better with anilin oil which renders the horny 
layers transparent. 

The incipient papules are punctiform, pink and glistening; they 
enlarge in a few days or weeks. Full-grown papules may remain 
isolated in discrete eruptions, but almost invariably they multiply 
and become confluent in plaques of very variable extent and round, 
oval, or irregular shape, usually thicker on the borders than in the 
middle, of a dusky red or brownish color. 

Their surface is covered with fine, very adherent, often scarcely 
visible scales, but the finger-nail passing over the surface leaves a 
scaly line. Horny granules are sometimes seen. The papules con- 
stituting the patch are sometimes recognizable, especially on the 
borders. Extensive plaques and patches, when there is complete 
confluence, are cut in squares by lozenge-shaped or polygonal 
designs Inning a smooth and glistening surface, producing a mosaic 
appearance. On the surrounding -kin isolated papules and other 
groupings may be seen. 



Fig. 33 




It is the rule for lichen planus, especially when the eruption has 
existed for ;i few weeks, to be accompanied by dyschromia. The 
papules and patches become more or less pigmented or become 
surrounded by ;i pigmented areola; sometimes, the center is color- 
less while the circumference is hyperpigmented, brownish or 
blackish. Tin- symptom may be absent. The coexistence of 
genuine vitiligo is not very rare. 

The most common localization of the eruption is the anterior 
surface of the wrists, the forearms and the legs; but it is also 
observed on the flanks, the lumbar region, the genital organs, the 
buccal mucosa, the neck, the palmar and plantar regions, rarely on 
the face and very exceptionally on the hairy scalp. The eruption 
may be almost universal, 



LICHEN PLANUS 133 

Pruritus may be altogether absent, often it is slight and inter- 
mittent; sometimes, very severe and even excessive to the point of 
interfering with rest. It may therefore be said that patients suffer- 
ing from lichen planus scratch themselves, "a little, a great deal, 
violently, or not at all." 

Scratching is undoubtedly responsible for the diffuse lichenization 
which frequently accompanies the typical eruption, sometimes 
concealing it. 

Varieties. — There exist several varieties of lichen planus char- 
acterized by a particular form of the eruptive lesions, or of their 
arrangement, by certain localizations, or by an abnormal course 
of the disease. 

The papules of lichen planus may assume the form of very 
regular rings, from 6 to 8 mm. in diameter, with a pigmented center; 
this form is encountered especially on the genital regions, on the 
internal surface of the arms, on the flanks and near the articular 
folds. The existence of a few rings in a typical eruption is not 
uncommon; they may predominate in a given region, constituting 
lichen annulatus. 

Sometimes, in the same regions, the papules are grouped in circles, 
with centrifugal extension, in gyrate or arabesque patterns; this 
condition is described as lichen marginatus sen serpiginosus. 

There also occurs an arrangement of the papules in linear streaks, 
apparently referable to streaks from scratching: lichen striatus; or 
following the course of a nerve after the manner of herpes zoster 
or a linear nevus: lichen zoniformis. 

In certain cases of lichen planus taking an acute or subacute 
course, the typical lesions may be associated with a few acuminate 
papules. It might be conceded that this partial and occasional 
irregularity is entitled to the special name of lichen acuminatus. 
However, at the International Congress held in Paris in 1889, the 
foreign authors present admitted that the majority of the cases, 
which with Kaposi they called lichen ruber acuminatus, actually 
belonged to pityriasis rubra pilaris, [described by Devergie and 
long known in France.] 

In the palmar and plantar regions (Fig. 32) the papules of lichen 
are sometimes horny, resembling vesicles at first sight; this des- 
quamation gives rise to a peculiar cribriform appearance. In other 
cases, the eruption manifests itself in the form of large irregularly 
outlined red and scaly spots, so that the diagnosis is far from easy. 

Lichen planus of the buccal mucosa is especially noteworthy on 
account of its frequency and its peculiar appearance. Familiarity 
with its characteristics may assist in the diagnosis of a doubtful 
case. Ignorance concerning them leads on the contrary to the 
unfortunately frequent confusion with leukoplakia or syphilis of 



134 PAPULES AND PAPULAR DERMATOSES 

the month. This localization of lichen is observed in about one- 
half [one-third?] of the cases; it may be primary, preceding for a 
long time the cutaneous eruption. Buccal lichen planus is painless 
and the patients having it are invariably unaware of its existence. 
The lesion consists either of opaline porcelain-like spots or of a 
white network, closely resembling, although on a much larger scale, 
the net which has been described in the typical papules of the skin. 

On the genital organs, notably on the glans and prepuce, umbil- 
icated papules and often circinate or annular forms are observed. 
Vulvar, urethral and anal lichen planus have also been reported. 

The ordinary course of lichen planus is sluggish. The eruption 
appears insidiously, progresses during a few months, then persists 
a variable time, sometimes for years, without changing. Generally, 
however, this course is interrupted by subacute attacks, for instance 
on the occasion of physical or emotional disturbances; the lesions 
multiply, new regions are invaded, there is a recurrence of itching. 
Retrogression is slow and imperceptible, the papules and patches 
usually leave very persistent and suggestive pigmented spots. 

The name acute lichen is used for a variety which takes a rapid 
course. In these cases, an extensive eruption suddenly appears 
over large surfaces of the trunk or the limbs. It consists of a 
diffuse redness, with swelling of the skin and some desquamation, 
on which can be made out minute incipient papules, the size of a 
needle-point; sometimes they can be seen only with a lens and 
when the skin is stretched. Examination by biopsy shows that 
even the smallest papules possess the characteristic structure. The 
eruption may be accompanied by some systemic disturbance. More 
particularly in acute lichen, although only in exceptional cases, 
a few ephemeral bulla? (lichen ruber bullosus), or sometimes acu- 
minate lesions may be seen. Acute lichen subsides in a month or 
two or it may pass into the chronic form. 

Pathological Anatomy. — The structure of the lichen planus papule 
is characteristic. The Malpighian body, from being at first con- 
siderably hypertrophied (acanthosis) is less markedly so later on, 
when the corneal layer has thickened at its expense. The granular 
layer is preserved and even hypertrophied (granulosis), but the 
keratohyalin is unevenly distributed in different points of the same 
papule. It gives rise to the pathognomonic network of the white 
or opaline streaks. The horny layer is thickened, coherent, loaded 
with fat and formed by normal non-nucleated cells (keratosis); in 
long-standing papules, nucleated corneal cells may be found, and 
corneal globes are sometimes seen at the orifice of a few follicles. 

The papillae are not elongated, but broadened into cupolas and 
are often slanting. The boundary line of the derma and the epi- 
dermis is therefore very irregular; it is usually somewhat obliterated 



LICHEN PLANUS 



135 



in places (Fig. 34, 6r). Sabouraud (1910) has shown that small 
serous effusions may be encountered in the basal layer of the epi- 
dermis, as well as a few giant cells of epithelial origin, either in 
the basal layer or much more rarely in the subjacent infiltration. 

The papillary body contains a diffuse infiltration composed of 
small round cells; some of these and sometimes a few Malpighian 
cells, may have undergone colloid degeneration. The lower limit 
of this infiltration is always markedly distinct; beyond it, only a 
few perivascular cuffs are demonstrable. 

The papule is accordingly of the mixed, epidermo-dermic type. 

I have described strictly analogous lesions in lichen planus of 
the mucous membranes; and in my opinion, the spots and white 
network are referable to the abundant newformation of kerato- 
hyaline. 




Fig. 34. — Histology of a lichen planus papule. A, acanthosis; B, granulosis; C, 
keratosis; D, colloid degeneration; E, diffuse infiltrate; F, cupola-shaped papilla; 
G, boundary line of derma and epidermis. X 37. 



Diagnosis. — The common error of mistaking lichen for a papular 
syphilide is not justified by any real resemblance. 

Secondary lichenizations have diffuse outlines; glistening facets 
may be found, but no papules as distinct as those of lichen planus; 
and the opaline streaks are absent. Real difficulties may arise, 
however, in some cases. 

Pruriginous eczema in children is not infrequently associated with 
small glistening papules. An observer who is not aware of this 
possibility may mistake the condition for an eczematized lichen 
planus or a diffuse prurigo; these papules are generally ephemeral. 

Circumscribed prurigo (the chronic lichen simplex of Vidal) 
occasionally very closely simulates lichen planus. Its papules are 
hemispherical, instead of plane, less glistening and are devoid 
of white streaks. 

Porokeratosis of Mibelli, which is very rare, and the palmar and 
plantar keratoderma and porokeratosis may cause serious difficul- 
ties in the differential diagnosis from lichen planus of the same 
regions. 



(.36 PAPULES AND PAPULAR DERMATOSES 

There is a form of lichen scrofulosorum with Mat and glistening 
papules, but without an opaline network; it is very rare. 

In lichenoid parapsoriasis, the analogy of the lesions with those 
of lichen planus is merely temporary; the course suffices for the 
differentiation. 

Acute lichen may be suggestive of erythroderma. 

Etiology and Character. — Lichen planus is a disease of adult life, 
more common in men than in women. [According to the American 
Dermatological Association's statistics, it is seen once in a little 
more than 200 cases of skin diseases.] 

It occurs so frequently in nervous, irritable individuals, in con- 
nection with a psychic shock, violent emotions, grief and worry, 
accompanied by insomnia, nervous excitement, neuralgias, etc., as 
to suggest its interpretation as the cutaneous manifestation of a 
nervous disturbance. This theory cannot be proved. I have not 
found lichen planus to manifest itself with special frequency during 
the war. [The nervous disturbances may well be the effect rather 
than the cause of this dermatosis.] 

Jacquet and others have advanced the view that the eruption 
is always secondary to scratching. It is perfectly true that a 
patient suffering from lichen planus will sometimes present a linear 
-erics of papules originating in a nail or pin scratch. Scratching 
an affected region may therefore be held responsible for the onset 
of a more profuse eruption. But on the other hand, itching is 
often entirely absent and lichen of the mucous membranes is never 
associated with any pruritic sensation. 

The nervous factor is sometimes absent. Apparently contagious 
cases have been reported, as well as other, more numerous, cases of 
familial lichen planus. 

The pathological anatomy would conform very well with the 
microbic theory; but this rests on no really conclusive fact. The 
question of etiology must therefore be left open. 

Treatment.— General Treatment. — General treatment ranks first 
in order of importance, being that of nervousness and pruritus. 
The dietetic regimen, general hygiene, and so forth, must be regu- 
lated according to the schedule given elsewhere. (See Therapeutic 
Notes, Section 12. J 

Hydrotherapy particularly the sedative lukewarm douches 
advocated by Jacquet as by themselves alone sufficient for the 
cure of obstinate cases of lichen planus- is often very efficacious. 
Various hot springs are of value. 

Electricity, in the form of static baths and especially high-fre- 
quency currents, has yielded remarkable results in my experience. 
Radiotherapy is applicable to localized eruptions. 

Thibierge and Kavaut have observed rapid cures following 



LICHEN PLANUS 137 

spinal puncture and have recommended this procedure in the 
treatment of the disease; its efficacy is not reliable. 

Among internal medicinal agents, arsenic is regarded as a specific 
by the Vienna School and by a number of dermatologists. It is 
prescribed in various forms and in large doses, but at intervals. 
Sodium arsenite, for example, may be given in doses of 4 mg. 
daily to begin with, increasing by 2 mg. daily until 12 to 15 mg. are 
reached, and then diminishing. Or from 5 to 12 mg. of potassium 
or sodium arsenite may be administered in daily injections. [Several 
American observers have reported good results from the internal 
administration of mercury.] 

Under these conditions [when the treatment is prolonged] arsenical 
poisoning may be expected; aside from digestive disturbances, 
cramps and formication, there is danger of palmar and plantar 
hyperkeratosis, or of greatly increased pigmentation of the spots, 
or even the development of melanoderma. Intravenous injections 
of arsenobenzol, while not possessing the same disadvantages, 
cannot be unconditionally recommended. 

Antipyrin, nerve tonics, salicylates, etc., are unreliable. 

Local Treatment. — Local treatment consists of various topical 
applications, pastes, salves and plasters made with calomel, yellow 
oxide, chrysarobin, even with sublimate; to the mercurials may be 
added phenol, menthol, tartaric or salicylic acids. Collodium with 
oil of cade is sometimes very successful in discrete eruptions. Appli- 
cations of potassium permanganate, in fairly strong solution, have 
been recommended by Hallopeau, even against buccal lichen 
planus, the treatment of which is extremely unsatisfactory. 

Atypical Forms of Lichen Planus. — Of the following dermatoses, 
some are varieties of Wilson's lichen, whereas others are probably 
independent of the same and will ultimately come to be classified 
in other nosographical groups. 

Atrophic or Sclerotic Lichen Planus, studied by Hallopeau and 
myself in 1887, is a legitimate lichen planus, the plane papules 
of which become depressed in the center which becomes cicatricial; 
they extend slowly at the periphery and become confluent with the 
neighboring lesions. The resulting atrophic spots are white or 
nacreous, rounded or poly cyclical. On their thinned epidermal 
lining corneal granules are sometimes found lying in the sweat 
and follicular orifices. These white spots may attain the size of a 
silver dollar. 

Histology shows that a sclerotic band has become interposed 
between the epidermis and the infiltration. When the process is 
checked, the papular border and the rose-colored areola disappear 
but the cicatrix is indelible (Fig. 35). 

The wrists, forearms, neck, breasts, abdomen and sometimes the 



138 



PAPULES AXD PAPULAR DERMATOSES 



thighs are the regions in which this variety of lichen has been 
especially observed. Zumbusch has described it under the new 
name of lichen albus, which was not needed.. 




Fig. 35. — Lichen planus atrophicus on the nape of the neck in a woman aged fifty- 
three years. 




1 [G. 36, — Lichen obtusus vulgaris of the leg. 



Lichen Nitidus of Pinkus is an eruption of small, flat, glistening, 
sometimes slightly dusky papules, which never becomes confluent 
and causes no itching. It is almost invariably localized on the penis, 
but may be generalized, persisting unchanged for years. Ilisto- 



LICHEN PLANUS 



139 



logical sections show a tuberculoid nodule, rich in giant cells, lying 
directly under the epidermis. 

Lichen Obtusus. — The name of lichen obtusus has been applied 
to various imperfectly understood eruptions with hemispherical 
papules. Lichen planus obtusus of Unna is characterized by dry 
scattered elevations, the size of a pea, brownish or purplish in color, 
not scaly, and only slightly pruritic. 




Fig. 37. — Lichen corneus hypertrophieus of the leg, in a man aged sixty-two years, 
who simultaneously presented lichen planus on the back of the hands. 



Lichen Planus Moniliformis of Kaposi seems to be a rare variety of 
lichen planus, with large hemispherical papules, arranged in strands 
[like a string of beads]. 

Lichen Obtusus Vulgaris consists of large, faintly pinkish or brown- 
ish papules, usually grouped in a single region and even confluent; 
I have observed it especially on the anterior surface of the legs 
(Fig. 36). It is more or less pruritic and runs a very protracted 
course. The elevations are often covered with a horny coat. 



1 10 PAPULES AND PAPULAR DERMATOSES 

The relations between this form and lichen planus are doubtful; 
it is often confused with the following: 

Hypertrophic Lichen Corneus or Lichen Verrucosus, consists of pink- 
ish or red warty protuberances, usually covered with very adherent 
brownish or chalky horny masses. They have the dimensions of 
a pea to those of nummular patches. They are disseminated, or 
more frequently grouped, or even confluent, in a roughly outlined 
network. Their surface may have an alveolar appearance, pro- 
duced by numerous corneal cones dipping into the cutaneous pores. 
Itching is variable, intermittent and inclined to be nocturnal. 

The seat of predilection of the eruption is on the legs, but it 
may also occupy the elbows, the Hanks and buttocks, etc. The 
microscope reveals a well-marked total epidermic hypertrophy and 
a considerable elongation of the papilla*. 

I have repeatedly demonstrated the coincidence of this lichen 
verrucosus corneus with typical lichen planus, or with buccal lichen 
planus, I have also seen lichen corneus developing on oozing or 
crusted eczematous foci (Fig. 37). 

It is, therefore, probable that various dermatoses may terminate 
in the clinical picture of lichen corneus hypertrophicus, eczemas, 
prurigos and lichens appearing among these affections. The 
course is very slow and the disease is extremely obstinate. 

The treatment of the atrophic and obtuse lichens does not differ 
from that of lichen planus. 

Hypertrophic Horny Lichen requires vigorous washing with soap, 
applications of caoutchouc or moist dressings for cleansing purposes, 
followed by strong reducing agents, notably chrysarobin. It is 
sometimes necessary to resort to the curette or the thermocautery. 
Hydrotherapy and radiotherapy are very valuable measures in 
these cases. 

PAPULES OF PRURIGO. 

Prurigo represents one of the most confused problems in derma- 
tology. The simplest way of settling it consists in calling prurigo 
all primary itching which is accompanied by certain special cuta- 
neous reactions, namely the papules of prurigo and lichenization. 

Pruritus and prurigo, as disease conditions, will be described 
further on (XXIV). 

Among their eruptive manifestations, those which assume the 
form of papules arc the only ones here to be discussed; it is desirable 
to consider them in connection with lichen papules, with which 
they are always liable to be confused. 

There exist two forms of papules in the prurigos: the papule 
of strophulus or acute prurigo and the papule of genuine or chronic 
prurigo. 



PAPULES OF PRURIGO 141 

The Papule of Strophulus. — The papule of strophulus is an 
elevation of the size of a large pin-head, lenticular shape, dusky 
or pinkish color and firm consistence (Fig. 148). Careful examina- 
tion shows it to be always centered by a yellowish point which is 
really a minute vesicle or tiny crust. It originates almost invari- 
ably in the center of a more or less transitory urticarial spot. Dur- 
ing the first hours, it is often necessary to stretch the skin at the 
site of this spot in order to bring out the papule hidden by it. The 
papule will appear like a droplet of wax; on palpation a firm round 
induration is felt. 

At the end of four to twelve hours, the urticarial spot disappears 
and the papule remains behind. It persists from eight to fifteen 
days; the crust which crowns it is demonstrable nearly to the end. 
When this crust has been torn away by scratching, it becomes 
replaced by a bloody crust. In disappearing, the papule often 
leaves a not very persistent pigmented spot behind it. 

In exceptional cases, smaller papules are met with, lasting only 
three to four days; larger reddish papules, the size of a lentil; 
papulo-vesicles with distinct vesicles, sometimes attaining the size 
of a pea, umbilicated or not, with clear or turbid contents. 

Histological examination shows that the strophulus papule is 
dermo-epidermic and consists of papillary edema and vascular 
dilatation with a diffuse infiltration of leukocytes; edema of the 
mucous body; a lenticular disk of colloid appearance situated 
directly under the horny layer and composed of parakeratotic 
corneal cells and edematous desiccated epidermic cells; spongiosis 
is regularly present beneath and on the borders of this disk. This 
structure is characteristic. 

The papule of strophulus, with its associated urticaria, is the 
special eruptive lesion of acute prurigo simplex, to which its old 
name of strophulus is advantageously reapplied. It is also met with 
rather frequently, but not invariably, in the first stage of Hebra's 
prurigo. 

The Papule of Prurigo. — The papule of prurigo has the following 
characteristics : Its volume usually varies between that of a millet 
seed and that of a large pea; its form is more or less hemispherical, 
rarely flat; its rounded, sometimes ovaloid contours are not quite 
distinctly outlined; its color is variable, sometimes of the same 
shade as the normal skin of the region, or it may have a more or 
less bright pink, darkened, yellowish or brownish hue; its consist- 
ence is more or less firm, never soft; its surface is either very smooth, 
almost glistening, or more often scaly, not infrequently excoriated 
and covered with a bloody crust. Briefly, it presents a considerable 
objective resemblance to the papule of lichen obtusus (Fig. 36). 

According to various authors, this papule may sometimes become 



142 PAPULES AND PAPULAR DERMATOSES 

crowned with an eczematoid vesicle, or it may undergo suppura- 
tion; I believe these are superadded lesions due to traumatism and 
infection. 

The structure of the prurigo papule can be defined in a few words; 
it consists of localized acanthosis; edema and infiltration are 
absent or slightly marked; Jadassohn, however, speaks of the 
frequent presence of large numbers of eosinophile cells in the 
derma; Leloir and Tavern ier have described an intra-malpighian 
cavity containing clear fluid and few leukocytes, said to be char- 
acteristic of Hebra's prurigo; I have never observed it. 

The prurigo papule is regularly met with in Hebra's prurigo in 
its second stage, in the form of a scattered eruption; it may reach 
the size of a hazel-nut in prurigo ferox (see Fig. 149). It is some- 
times observed in diffuse prurigo vulgaris, but almost invariably 
in circumscribed prurigo (chronic lichen simplex of Yidal). It 
must not be confused either with the papule of strophulus or with 
the papule of lichen planus and especially not, as is frequently done, 
with excoriated follicular papules which will be discussed in describ- 
ing the other cutaneous manifestations of pruritus and prurigo 
(p. 487). 

PAPULAR SYPHILIDES. 

Papular eruptions are among the common manifestations of the 
secondary stage of syphilis and their recognition is accordingly 
important. 

They are classified, according to the dimensions of the lesions, 
into syphilides with small papules, which will be described with 
the folliculoses (for they are always peripilar); syphilides with 
medium-sized lenticular papules and syphilides with large papules, 
or papulo-nummular syphilides. 

Lenticular papular syphilides are perfectly round, disk-shaped 
protuberances, of a pinkish (later red or ham-colored) rarely cop- 
pery hue, firm to the touch and giving the sensation of a sharply 
circumscribed dermic infiltration. 

On their surface the epidermis is raised in a fine glistening layer; 
when this is detached, a scaly border is left, known as Biett's 
collar; the last-named sign may be absent and is moreover not 
absolutely pathognomonic. Not uncommonly, there is more 
profuse desquamation and the lesion may then be named papulo- 
squamous syphilide. 

Lenticular syphilides are common, sometimes following the 
roseola through a papular transformation of the spots (papular 
roseola), or becoming intermingled with the latter (erythemato- 
papular syphilides), or they may constitute a syphilitic eruption 



PAPULAR SYPHILIDES 143 

by themselves. These attacks have a tendency to recur, especially 
in the course of the first year, in insufficiently treated patients. 

The eruption is usually abundant, symmetrical, very irregularly 
scattered over the trunk and limbs, even on the face and on the 
palmar and plantar surfaces. It is often associated with mucous 
patches, alopecia, sometimes with pigmented syphilides, nodular 
syphilides or other complicated eruptions. 




Fig. 38. — Eruption of lenticular papular syphilides, mixed with a few follicular 
syphilides. 

It lasts from ten to thirty days when treated, from two to three 
months in the absence of specific treatment. The papules leave 
in their place reddish, sometimes pigmented hyperchromic spots, 
especially on the lower limbs, very persistent and most distressing 
to the patients. Such cases were described by Fournier under the 
name of syphilides nigricantes . The occurrence of atrophic spots 
or macules has also been observed (Fig. 38). 

Several deformities or irregularities of the lenticular papules and 
papulo-squamous syphilides are known to occur. They become 



144 



PAPULES AND PAPULAR DERMATOSES 



papulo-erosive, under the influence of maceration, in the axillary, 
inguinal, intergluteal folds, at the umbilicus and around the geni- 
tals. This aspect is frequently seen in congenitally syphilitic 
infants, on the buttocks, the back, the neck, the genital regions and 
sometimes involves the entire lower limits. 

In the seborrheal regions papular syphilides are arranged in 
certain eases in manunillate, circinate or irregular-shaped patches, 
covered with greasy crusts, these are designated as seborrheal 
syphilides and on the forehead constitute the corona veneris; they 
are very resistant to treatment, unless appropriate topical agents 
are employed together with the specific medication. 

The psoriatiform, papulo-crusted and fungoid varieties of the 
papular syphilides have been mentioned already or will be discussed 
later. 




Fig. 39.— Arcif 



Aii interesting (because absolutely pathognomonic) form is that 
of the papulo-drcinate or arcif orm [or annular] syphilide (Fig. 39). 
This is observed only in the course of the first year and in young 
women who have already been treated. [It is not uncommon in 
the negro race in both sexes.] It presents the appearance of 
regular rings, graceful arcades or complicated circulations, on the 
chin, around the lips and nostrils, or sometimes on the vulva. 
The circles are continuous or formed by small fine-scaly papules 
having a yellowish-pink color. 

Papulo-nummular syphilides are discoid or oval prominences, 
from 1 to 3 cm. in diameter; on account of their form and their 
ordinarily oozing or crusted surface, they have been named cuta- 
neous patches (Bazin), syphilitic patches (Legendre), or mucous 
patches of the skin. 



LICHEN SCROFULOSORUM 145 

These syphilides are extremely common in the ano-genital region, 
but may develop in any skin fold. They are also met with in 
association with a papulo-lenticular eruption, on the neck, the face, 
the shoulders, etc., but are not numerous there. They might be 
confused with iodide eruptions, but these are pustular and grow 
much more rapidly. 

All these papular syphilides have a nearly identical structure (Fig. 
31); they are composed of an intradermic plasma-cell infiltration 
and differ among themselves only by the lesions of the epidermis. 

The diagnosis of papular syphilides is usually easy. Lichen 
planus, psoriasis and parapsoriasis differ from these syphilides by 
the features of their own lesions. The papules of the diffuse and 
circumscribed prurigos are distinguished by the very active pruri- 
tus by which they are accompanied. Hydradenomas of the thorax, 
which are very rare, have an analogous appearance but their 
duration is indefinite and their localization is strictly limited. 

Papulo-necrotic tuberculides may give rise to serious diagnostic 
difficulties, although it is known that they chiefly affect the limbs, 
that their development is successive and usually slow, that they 
become hollowed out by ulceration and leave a cicatrix. In a 
given case, however, the decision may have to be based upon the 
coexistence of other specific manifestations, biopsy and serodiagnosis. 
The diagnosis of posterosive syphiloids in the newborn is still 
more difficult. Mistakes are common and seriously detrimental to 
infants wrongfully suspected of syphilis. The presence of other 
manifestations of congenital syphilis, the condition of the parents 
and the course of the eruption, permit a positive diagnosis in some 
cases. The Wassermann reaction of the child and its mother must 
be determined in doubtful cases and sometimes biopsy and a search 
for spirochetes is called for. 

LICHEN SCROFULOSORUM. 

Lichen scrofulosorum is a papular eruption resembling lichen in 
its clinical appearance, but in its nature related to the tuberculides 
or attenuated tuberculoses of the skin. 

It will be seen further on that the tuberculides constitute a group 
of dermatoses of identical etiology, but extremely polymorphous 
objective characters. The most frequent and distinct forms have 
received special names, the others are considered as intermediary 
forms. 

My description deals with the most pronounced type of the 
papular tuberculides; but it must be emphasized from the start 
10 



146 



PAPULES AND PAPVLAli DERMATOSES 



that there exist numerous atypical and less distinctly characterized 
varieties. 

Lichen scrofulosum of Hebra, the papular scrofulide of Bazin — 
a better name for vhich would be lichenoid tuberculide — presents 
the following appearance: 

An eruption of small papules, of the average size of a pin-head 
slightly prominent, flattened, polygonal, of a pale yellow or more 
rarely a dusky red color, of rather soft consistence, a surface smooth 
and glistening or more commonly covered by a slightly adherent 
scaly layer, such is the typical form (resembling the papule of 
lichen planus) which is, however, not the most frequent. 

These papules are almost invariably grouped in more or less 
numerous nummular plaques or in patches, rings, or semicircles; 
also as an irregular network, the interpapular areas remaining 
normal. 

The eruptions usually occur on the trunk, especially the flanks and 
loins, but may spread to the limbs and exceptionally to the face. 
It appears insidiously, almost without pruritus, persists during 
several months and then disappears leaving no trace of any kind. 
Sometimes recurrences develop in attacks during several years. 




FlG. 40. — Lichen scrofulosorum, acuminate variety. (This group of papules 
suddenly appeared on the back of a young woman suffering from lupus, shortly after 
an injection of tuberculin). 



There are numerous varieties, and the following forms may be 
found associated with the flat and glistening papules, in the 
same or in different regions, or constituting by themselves the 
entire eruption: conical or acuminated papules, of a rose-red color 
(Fig. 40) and centered over a follicle the hair of which may be 
broken off flush with the orifice; in other cases, conical papules 
crowned by a vesico-pustule, of the type of acne cachecticorum ; 
or again, confluent lesions may form scaly polygonal disks, of a 
purplish or brownish-red color, slightly infiltrated, not very promi- 
nent, which resemble psoriasis or some of the eczematides; and 
finally, the eruption may present a mixture of follicular papules and 



LICHEN SCROFULOSORUM 147 

patches dotted with acuminate lesions suggestive of pityriasis rubra 
pilaris or lichen spinulosis. 

Under the heading of lichen scrofulosorum there should also be 
grouped, according to Boeck, as deformed or attenuated varieties: 
his disseminated papulosquamous tuberculide; his eczema scrofulo- 
soram, characterized by crusted and oozing patches with an infiltrated 
base constantly recurring at the same points; certain forms of 
pityriasis simplex of the face in children, arranged in circumscribed, 
red, fine-scaling patches and accompanied by large cervical glan- 
dular swellings. 

Lichen scrofulosorum is observed at all ages, but occurs by predi- 
lection in children and youthful individuals suffering from glandular 
or bony tuberculosis or from sluggish visceral tubercular lesions. It 
has been known to follow acute diseases, such as measles, etc. 

The papules are formed, as was first shown by Jacobi and Sack, 
by a dermic infiltration having almost invariably the constitution 
of characteristic tubercular follicles, with giant cells, but with a 
slight tendency to caseous degeneration ; these tubercles are situated 
in the papillary body or around a pilo-sebaceous follicle. 

Jacobi, Sack and Wolff succeeded in finding the Koch bacillus in 
their specimens and in a few of their cases guinea-pig inoculation 
proved positive. 

A general and local tuberculin reaction is practically constant; 
Jadassohn obtained a positive reaction in 14 out of 16 cases. 
Schoeninger, Buzzi and myself have observed the appearance of 
lichen scrofulosorum immediately after injections of tuberculin, 
which undoubtedly merely served to bring out latent lesions (Jadas- 
sohn, 1896). 

The diagnosis of lichen scrofulosorum may present very con- 
siderable difficulties. In view of its habitual polymorphism, it is 
advisable to examine not only one eruptive group but the erup- 
tion as a whole ; thereby guarding against confusion with the 
eczematides, lichen planus, acne cornea, abortive forms of pityriasis 
rubra pilaris, etc. 

The differential diagnosis from the follicular lichenoid syphilides 
is sometimes almost impossible, even on examination by biopsy. 
The Wassermann reaction is of great help in these cases. 

The treatment is that of tuberculosis in general: fresh air, sun- 
light, cod-liver oil, calcium compounds and arsenic; tuberculin in 
very minute doses or novarsenobenzol may lead to rapid improve- 
ment. Locally weak reducing agents and cod-liver oil ointments 
have been recommended. 



CHAPTER VIII. 
VESICLES AND VESICULAR DERMATOSES. 

Vesicles are small circumscribed elevations of the epidermis 
containing a clear fluid. Their size varies from that of a pin-head to 
that of a pea; their form is hemispherical, or sometimes acuminate 
or umbilicated; their outline is round; or, as the result of confluence 
they may assume an angular or polycyclical configuration. 

The contents of the vesicles are fluid and transparent like water 
or yellowish and serous. It is sometimes necessary to prick the 
roof with a needle in order to demonstrate the presence of the fluid 
and its properties. The contents are apt to become cloudy or turbid 
after a time; sometimes they are hemorrhagic from the start. 

As the result of desiccation, the vesicles are transformed into 
crusts whose origin is indicated by their shape and arrangement. 

On the mucosa? and semimucosse, as well as in regions where skin 
rests against skin, the vesicles rupture very readily leaving red 
erosions or often diphtheroid lesions of rounded or polycyclic 
contours. 

Modes of Formation of Vesicles. — They always result from an 
accumulation of plasma in the epidermis. Vesiculation may occur 
in three different ways which are, however, frequently combined. 

In the first, or parenchymatous vesiculation, the fluid accumulates 
first in the interior of the Malpighian cells and the resulting uni- 
cellular vesicles become confluent with each other. This so-called 
"alteration cavitaire" of Leloir predominates in smallpox, vaccinia, 
etc. 

In a second type, or interstitial vesiculation, the edema is inter- 
cellular, compressing and stretching the Malpighian cells which 
are drawn out into a net, the threads of which finally rupture, pro- 
ducing the spongioid state of Unna, the spongiosis of Besnier. The 
vesicles of eczema are produced in this way (Fig. 5). 

In a third type, the edema is likewise intercellular, but the cells 
become globular, are detached from each other and float in the 
fluid, undergoiag a cloudy or fibrinous degeneration, sometimes 
becoming hypertrophied with multiplication of their nuclei. This 
is the ballooning alteration of Unna, which predominates in the vesi- 
cles of varicella, zona (Fig. 41), herpes, etc. 

Whatever the mechanism of their production, vesicles always 



MODES OF FORMATION OF VESICLES 



149 



result from an inflammatory process and constitute acute eruptions 
on a hyperemic base. 

Vesicles differ from bullce not only by their usually smaller 
volume but also by their mode of formation. In contradistinction 
to bullae, they are frequently multilocular, at least at their inception. 

They differ from serous cysts, notable from the hydrocystomas 
and lymphatic varices which may simulate them, by the intra- 
epidermic seat of their fluid ; they can be opened by puncture without 
causing hemorrhage. 




Fig. 41. — Section of a zona-vesicle on the tenth day. Vesiculation through bal- 
looning alteration ; in the center of the vesicle all the cells of the rete are degenerated 
and the papillae are exposed. In the cutis an abundant infiltration of lymphoid 
cells is seen. X 50. 



Vesicular Dermatoses. — Vesiculation is observed in the eruptive 
fevers, variola, varicella and vaccinia, for which the reader is 
referred to text-books of general medicine. 

In eczema from any cause, vesiculation is very common; it has 
even been considered as characteristic of the eczematous process. 
It may be absent, however, and at any rate represents merely 
a stage or episode of eczema, which was discussed in a chapter bv 
itself (IV). 

The vesicles of cutaneous trichophytosis, formerly called herpes 
circinatus seem to me to be of eczematous character; they will be 
mentioned in the chapter on parasitic dermatoses, as will also those 
which complicate scabies. 

Sudamina, notwithstanding their small size, are not vesicles but 
minute subcorneal bullae; they will be discussed together with the 
hidroses. 

In recurrent polymorphous pemphigus, commonly known as 
dermatitis herpetiformis of Duhring, genuine vesicles are found at 
the same time as real bulla?; this affection is in every respect related 
to the bullous dermatoses. 

The eruption of strophulus is usually papular; it is exceptional for 
the microscopical vesicle which crowns its papules to assume a 



L50 VESICLES AND VESICULAR DERMATOSES 

development rendering it visible to the naked eye; however, certain 
very rare eases have simulated varicella. This affection belongs to 
the group of the prurigos. 

In this chapter there remains to be studied only herpes, zona 
and the zosteriform eruptions. These are purely and exclusively 
vesicular eruptive syndromes. 

HERPES. 

Herpes is an acute eruption of a cluster of vesicles, varying in 
number and originating on an erythematous base, situated any- 
where, although having a predilection for the face, around the mouth 
and the nose and for the genital region. The affection is extremely 
common and known to the laity under the name of "fever blister." 

The word herpes formerly had a much more restricted significance. 
The terms herpetism, herpetides, no longer possess any accurate 
meaning. The name of herpes is still used for some dermatoses of 
very variable kinds, such as herpes circinatus, herpes gestationis, 
herpes iris, herpes cretaceus, etc., which are in no way related to 
genuine herpes. Zona is also known as herpes zoster. 

Symptoms. — Frequently preceded a few hours by shooting pains 
or a tense and burning sensation, herpes appears in the form of a 
congestive edematous spot, which promptly becomes covered with 
uniform vesicles, the size of a pin-head, with clear contents, from two 
or three to several dozen in number. These vesicles lie very close 
together and sometimes become confluent. They are rarely hemor- 
rhagic. There may be several as if accidentally scattered groups. 
The lymph glands are slightly enlarged. 

The herpetic vesicles became turbid, then opaque and shrivel up, 
forming yellow or brown crusts which become detached at the end 
of eight to ten days, leaving a temporarily red spot, but never a 
permanent scar. Herpes has a marked tendency to recurrence. 

The seat of election of herpes is the lips, the nostrils, or any part 
of the face; or the genital regions. Herpes is also not infrequently 
seen on the lobes of the ears, the nipples and the mucous membranes; 
but. is much rarer on the trunk and limbs. As a rule, only one of 
these regions is affected at the same time. In the course of the War, 
however, I was enabled to observe in young soldiers recently vac- 
cinated against typhoid fever, profuse eruptions of herpes occupying 
simultaneously the forehead, the nose, both lips, the mouth, the 
chin, the ears, the neck, and in one instance one of the upper extremi- 
ties; the condition being suggestive of so-called multiple zona. 

Herpes genitalis [or progenitalis] is especially noteworthy on 
account of the liability to misinterpretation. Li men, it occupies 
the balano-preputial sulcus, the glans, the prepuce, or more rarely 



HERPBS 



151 



the meatus. On the parts covered by the clothing, it is rapidly 
transformed into erosions. These are very superficial, isolated or 
confluent, round or polycyclic and microcyclic, red or diphtheroid; 
some fluid can be squeezed out of them and they are slightly painful. 
Herpes is not indurated at the base, provided it is not improperly 
treated or abused, and heals in at most eight or ten days. [On the 
glans a certain degree of induration is common and must be con- 
sidered in making a diagnosis.] When the lesion has been cauterized 
or treated with irritants or antiseptics (silver nitrate, sublimate, 
tincture of iodin, aristol, etc.), always an improper procedure, it 
may become indurated, associated with inflammatory phimosis and 
painful swollen glands, ulcerate and last several weeks. In such cases 
an immediate diagnosis is extremely difficult, sometimes impossible 
before the inflammation has been relieved by soothing applications. 




Fig. 42. — Profuse vulvar herpes, showing eruption of relatively moderate severity. 



In women, herpes may occupy any portion of the vulva, presenting 
the same features as in the male. It is met with exceptionally in the 
vagina and the cervix uteri. 

A profuse vulvar herpes sometimes occurs (Fig. 42) with some 
fever, severe burning sensation, very marked local edema, extensive 
patches covered with agglomerated or confluent vesicles, extending 
from the vulva to the pubis, the internal surface of the thighs and 
in the intergluteal fold. The macerated vesicles rapidly break, are 
transformed into erosions or become covered with a diphtheroid 
layer and secrete an offensive muco-purulent discharge. The glands 



L52 



VESICLES AND VESICULAR DERMATOSES 



are swollen and painful. The patient suffers great inconvenience and 
is confined to bed. Healing takes place in fifteen or twenty days. 
In some cases under my observation, the lesions became promi- 
nent after epidermization had occurred, closely simulating papular 
mucous patches. 

Aside from the inconvenience and actual pain caused by it, genital 
herpes is important on account of its tendency to recurrence and 
because it prepares the soil for severe infections, soft chancres and 
syphilis, in persons exposing themselves to risk of these diseases. 




I K.. 13. Recurrent herpes of the che 
taken two years previously by Brocq, is s 
280; illustrating a more discrete eruption i 



\ photograph of the same young girl, 
n in his Traite de Dermatologie, ii, p. 

ie same a iva . 



It must also be kept in mind 
or accompany the onset of 



t an eruption of herpes may precede 
/philitic chancre which may conse- 
ain unrecognized for some length of 



quently pass unobserved ot 
time. 

Herpes buecalis is less common, and is usually met with in connec- 
tion with a profuse herpes of the lips or the face; it may occupy 
the mucosa of the cheeks, the palate and the tongue. It is often 
bilateral. Its vesicles are ephemeral. 

Herpes of the pharynx seems to constitute one of the varieties of 
herpetic angina, characterized by the abruptness of its onset, the 



HERPES 153 

rapidly rising temperature, the severity of the local pain and the 
marked general phenomena. Vesicles are occasionally found, but 
more often polycyclic erosions, diphtheroid or not, which succeed 
them. In doubtful cases, these erosions can be brought out, as on all 
mucous membranes, by painting them with a weak solution of silver 
nitrate, or better with a watery solution of chromic acid, 1 to 50 (L. 
Jullien). The glands are usually swollen and painful. 

Heroes conjunctivalis represents one of the forms of phlyctenular 
conjunctivitis. 

Recurrent herpes is that form which recurs, not accidentally and 
at any point, but with a certain periodicity and in a practically 
constant region. 

Certain women have an eruption, either around the mouth or on 
the genitals, at nearly every menstrual period (catamenial 
herpes) . 

Recurrent pro genital herpes, more particularly observed in men, 
is considered by Diday and Doyon as related to an existing or 
preceding venereal disease, especially soft chancre, gonorrhea and 
syphilis. 

Recurrent herpes of the face affects children and youthful indi- 
viduals, returning periodically several times in the course of the 
year on the same cheek, for ten years or more (Fig. 43). 

Recurrent herpes of the buttock occurs in adults of both sexes, and 
takes a more variable course. 

Recurrent herpes of the mouth, pointed out by A. Fournier, the 
distress of some old syphilitics, is referred either to remains of long- 
cured specific lesions, or to abuse of mercury. 

These various recurrent herpetes are not infrequently associated 
with neuralgic pains, burning sensations, painful tension, glosso- 
dynia, etc. 

Etiology. — Herpes is observed at any age, but especially during 
youth and maturity. Its causes are complex. There undoubtedly 
exists a traumatic herpes; dentists, for example, are familiar with 
the herpes developing around the mouth as a sequel of dental opera- 
tions ; on the other hand, herpes of the vulva is not uncommon after 
the first sexual intercourse. In both cases, the patients are much 
inclined to suspect that they have been infected. 

Many cases of recurrent herpes of the nose, the lips, etc., have 
seemed to me to be related to a chronic irritation of the neighboring 
cavities, dental caries, alveolitis, pulpitis, gingivitis, rhinopharyngitis, 
sinus inflammations, otitis, etc. The nervous and probably reflex 
character of many cases of herpes is therefore obvious. On the other 
hand, there are cases of symptomatic herpes, in certain infections. 
Herpes is known to be common in pneumonia, epidemic cerebro- 
spinal meningitis, influenza, etc. Sometimes a high fever of a few 



154 VESICLES AND VESICULAR DERMATOSES 

days' duration is terminated by an eruption of herpes, whence the 
assumption of a herpetic fever. 

A fairly well marked lymphocyte reaction of the cerebrospinal 
fluid was noted by Ravaut and Darre in 21 of 2(5 cases of genital 
herpes. 

The disease is not contagious, nor can it be inoculated. Neverthe- 
less, it is difficult to reject the idea that such an acute and severe 
dermo-epidermic lesion often accompanied by glandular enlarge- 
ment, constitutes an [infectious] inflammatory reaction rather than a 
" trophic disturbance." 

Treatment. — Herpes of the skin requires no active treatment, 
it suffices to cover it with a bland powder; herpetic eruptions can 
sometimes be aborted by dressings with absolute alcohol (90 per 
cent), or with borated or camphorated alcohol; but failures are the 
rule. Watery dressings and ointments are injurious, except in the 
stage of complete desiccation. 

Genital herpes must be gently treated; all irritant applications 
involve the risk of changing its appearance and prolonging its dura- 
tion. It suffices to wash or bathe it with lukewarm boiled or borax 
water, or an infusion of bran; to powder it with talcum, or zinc 
oxide, or bismuth subgallate. Touching with a drop of silver nitrate, 
5 per cent. , is permitted and useful , but only when the diagnosis is posi- 
tive and when the erosion fails to become covered with epidermis at 
the end of a few days. [Inasmuch as a herpes may lodge a spirochetal 
infection cauterization must in general be avoided.] Profuse herpes 
of the vulva requires rest in bed ; the pain is relieved by poultices of 
starch or cooling creams. 

In the case of recurrent herpes, the essential point is the dis- 
covery of the initial focus of chronic irritation and its removal. 
Radiotherapy has repeatedly proved successful in my experience 
in the cure of recurrent herpes of the buttock and the cheek. 

ZONA. 

Zona— or herpes zoster — is an acute eruption of vesicles, grouped 
upon erythematous patches and ordinarily located along the dis- 
tribution of a nerve, on only one side of the body. Its development 
is approximately cyclic; it recurs but rarely. 

Symptoms. — The eruption appears suddenly and is accidentally 
discovered by the patient, or it may be preceded by prodromata 
and accompanied by pains. 

At the onset, nothing is seen but slightly elevated erythematous 
patches, with a shagreened surface, of oval or irregular outlines, 
from a single one to twenty in number, generally half a dozen, 
separated by areas of healthy skin. At the end of a few hours, 



ZONA 155 

at most a day, vesicles form first in the center, then on the entire 
patch, and rapidly increase in size; they become tense, pearly, 
uniform, from the size of a small to a large pin-head. They lie close 
together, more rarely discrete, sometimes confluent. 

Their fluid content becomes opalescent and turbid, even purulent, 
by the third day, while at the same time the plaque fades and 
flattens; desiccation begins from the fourth to fifth day and is com- 
pleted by the eighth to twelfth day ; the crusts do not fall off until 
the end of twelve to twenty davs. 




Fig. 44. — Zona, on the tenth day of the eruption, occupying especially the cuta- 
neous territory of the II and III left lumbar roots. Near the groin the patches are 
confluent, the largest vesicles are hemorrhagic; numerous incomplete vesicles are also 
seen. Near the knee the patches are isolated and typical. 

The onset of the various patches is usually not simultaneous but 
successive, in the course of two or three days, so that several stages 
can be observed at the same time (Fig. 44). It frequently happens 
that the eruption remains incomplete on certain patches, especially 
the last to appear. From the start, or at the end of one or two 
days, the fluid of the vesicles may assume a sanguinolent character, 
constituting hemorrhagic zona. 

It is rare for the vesicles to rupture. When they are opened in 
the stage of suppuration, erosions or even fairly deep ulcerations 
which heal slowly are found beneath them ; in this case, the eruption 
leaves behind it, not only brownish macules, as is usual, but indelible 
white scars with pigmented halos, sometimes cheloids, having a 
characteristic distribution. This possibility must be mentioned to 
the patient. 

In cachectic or weak and senile individuals, genuine sloughing 



156 VESICLES AND VESICULAR DERMATOSES 

scars may supervene, representing gangrenous zona, with a prognosis 
sometimes serious. 

The lymph glands corresponding to the territory of a zona are 
nearly always enlarged, sometimes before the eruption appears. 
Outside of this territory, the skiu is healthy. However, the possible 
presence of aberrant vesicles, at a distance from the regional eruption, 
has been pointed out by Tenneson. In a contribution to this sub- 
ject (dedicated by me to Professor Barduzzi, of Livorno, in 1911) 
it was noted that this observation is correct, but that, leaving out 
of consideration the ordinary follicular inflammations and lesions 
of miliary impetigo which may accompany the disease, genuine 
aberrant vesicles in zona are relatively rare. [During an outbreak 
of smallpox in New York in 1900 I observed several cases of gener- 
alized herpes zoster in which the eruption was so extensive as to 
require careful examination before varicella could be excluded.] 

Pain is variable or may be absent. Almost invariably, however, 
zona is either preceded for several days or even several weeks, or 
accompanied, which is more common — or followed, by neuralgic 
pains; these pains are continuous or paroxysmal and may assume 
all possible forms, especially a severe burning sensation (hence the 
popular name of St. Anthony's fire). The patches themselves are 
sometimes anesthetic, it is claimed, but really almost invariably 
hyperesthetic. The frequency, severity and duration of the pains 
arc dependent upon the age of the patient; they are usually absent 
in children, but in aged individuals may persist indefinitely, causing 
extreme distress. 

The eruption of zona may be preceded by general phenomena, 
malaise, prostration, anorexia, with a transitory fever of 39° or -40° 
[102°-104°]. In this case, the infectious behavior of the disease, 
its sometimes epidemic and immunizing character, have caused it 
to be likened to the eruptive fevers: the zoster fever of Landouzy and 
Erb. The course of the disease may be described as nearly cyclical. 

Among the localizations of zona, the most common is intercostal 
zona, to which the disease owes its name. It covers the thorax or 
the abdomen like a half-belt, without passing more than a few 
millimeters at most beyond the median line. When it occupies the 
territory of the first intercostal nerves, it follows the anastomotic 
branch which the second intercostal nerve sends to the internal 
brachial cutaneous nerve down the inner surface of the arm. 

Cervical zona, which affects all or only some of the branches of 
superficial cervical plexus, is likewise fairly common and the same 
remark applies to lumbo-abdominal and genito-crural zona. Periph- 
eral zonas, affecting the limbs, are more unusual. 

Ophthalmic zona, corresponding to the superior branch of the 
trigeminal nerve, is frequent and grave on account of its possible 



ZONA 157 

sequelae. It presents frontal, palpebral, nasal, even pituitary 
patches and in two-thirds of the cases gives rise to ocular lesions, 
especially of the conjunctiva and cornea, lesions of the iris and 
amblyopia being less common. Anesthesia of the cornea, corneal 
perforation, irido-choroiditis and retinitis have been reported but 
are very rare. Ophthalmic zona must not be confused at the start 
with erysipelas or with keratoconjunctivitis from other causes. 

Zonas of the mucous membranes, buccal, pharyngeal, etc., are of 
very exceptional occurrence. 

Zona is almost invariably unilateral and may occupy the territory 
of a single nerve ; as. a rule, however, it spreads over the territory of 
two or even three neighboring spinal roots, 

Exceptionally, cases of double or bilateral, alternating, multiple, or 
even generalized zona are encountered, such as a case reported by 
Colombini in 1893. 

Zona usually occurs only once in a life-time, but recurrences have 
been noted in a few instances. So-called zonas with multiple recur- 
rences belong to the zosteriform eruptions. 

Etiology and Pathogenesis. — Zona affects all ages and both sexes 
equally. It is slightly more common in the spring. The cause as 
a rule remains entirely obscure. It has been observed to follow after 
severe traumatisms, violent emotions; to occur in the course of 
infections or general diseases, at the beginning or in the course of 
tuberculosis (Leudet), pneumonia, pleurisy, syphilis, cerebrospinal 
meningitis, mumps, carbon monoxid poisoning, arsenic medication 
(Hutchinson, Neilson), diabetes, cancer, etc. 

A number of circumstances indicate the infectious nature of zona, 
at any rate in many cases. It is true that the disease is not con- 
tagious, but it sometimes seems to be vaguely epidemic, in the sense 
that several persons from the same environment are attacked at 
intervals of a few days. It may be accompanied by general phe- 
nomena; glandular swelling is usually present. Sabrazes and Mathis 
have demonstrated the occurrence of hyperleukocytosis in the course 
of zona, especially of the polynuclears and the eosinophiles. Finally, 
an attack of zona usually confers immunity against another. The 
pathogenic agent, however, has not as yet been demo istrated. 

On the other hand, the relations of zona with the nervous system 
are very striking, in the distribution of the eruption as well as the 
associated neuralgias. I have seen a case of ophthalmic zona 
following upon a severe contusion of the skull in an automobile 
accident. Mme. Dioudonnat-Lempert devoted her thesis (1914) 
to the study of cephalic or cervical zona of dental origin. Lesion 
of a nerve branch in the course of a mercurial injection may give 
rise to a cluster of zona-vesicles along its area of distribution. 
Otic or para-auricular zona is not infrequently associated with 
facial paralysis. 



i:»S VESICLES AND VESICULAR DERMATOSES 

It lias recently been shown that in the course of syphilis, zona 
may indicate a premature syphilitic meningitis which affects the 
posterior roots, or it may precede tabes and general paralysis. Zona 
is also sometimes encountered in syringomyelia, in dementia, 
vertebral tuberculosis, cancer of the vertebra, etc. It is often accom- 
panied by lymphocytosis of the cerebrospinal fluid ; in different cases, 
this may exist prior to the eruption, coincide with it, or follow several 
days later; or it may be entirely absent. More rarely, rigidity at 
the nape of the neck, Kernig's sign, retardation of the pulse, head- 
ache, etc., have been noted. 

Numerous authors have demonstrated neuritis or degeneration 
of the nerves in the affected area. However, as the distribution of 
zona is far from being always in exact conformity with the distribu- 
tion of the corresponding peripheral nerves, a lesion of the spinal 
root and especially of the spinal ganglia is now held to be responsible. 
Following Baerensprung and Charcot, various observers have 
formed hemorrhagic, inflammatory, or degenerative lesions of the 
spinal ganglia and the posterior roots in cases of zona; among these 
writers, Head and Campbell must be specially mentioned (in 31 
cases). Head in England, Brissaud, Achard, and others in France, 
have endeavored to refer zona to a lesion of a spinal or metameric 
segment. 

At the present writing, the conclusion seems justified that the 
metameric theory is probably true for certain cases; that the radicular 
and ganglionic theory serves to explain the great majority of zonas, 
as has been confirmed by anatomical findings; finally, that the 
peripheral nervous theory applies to certain rare cases. 

Granted that the necessary pathogenic condition of zona is a 
lesion at some point in the course of neurons which supply the 
affected territory, one is justified in admitting that this lesion can 
be, in different eases: (1) of traumatic origin; (2) of toxic origin 
(arsenic, CO); (3) of autotoxic origin (diabetes); (-1) finally, of 
infectious character, either ordinary (tuberculosis, syphilis, pneu- 
monia, grippe, etc.), or sometimes due to a specific germ. The 
probable existence of this special microbic agent, which still remains 
unknown, would serve to explain the epidemic character, the pro- 
dromata, the febrile and infectious symptoms, the aberrant or dis- 
seminated vesicles, the immunizing power against a new attack 
which is characteristic of certain zonas and the so-called zoster- 
fever of Landouzy and Erb, or idiopathic zona. 

Jadassohn points out that according to this interpretation, zona 
is the perfect type of a .syndrome with an always identical mor- 
phology and pathogenesis, but a variable etiology. 

Diagnosis. In typical cases, this is extremely easy; the eruption 
of clustered vesicles, arranged in groups over one or more nerve 
territories, unilateral, accompanied by pain and taking a cyclic 



ZONA 159 

course, is absolutely characteristic. Doubt is possible only in incom- 
plete or abortive cases. A careful examination will guard against 
confusion with erysipelas, eczema, or polymorphous erythema. The 
differential diagnosis may occasionally be difficult from herpes and 
the zosteriform eruptions. 

Herpes is identical as regards the eruptive lesions, but is suffi- 
ciently characterized by its site, its frequently bilateral appearance, 
and its liability to recurrence. In the very unusual case of a single 
patch of zona, or in the presence of certain bilateral zonas, the differ- 
entiation may prove practically impossible. 

The zosteriform eruptions constitute a somewhat indefinite group, 
including rare and rather dissimilar observations. This name is 
applied to exanthems constituted by less numerous, less definitely 
grouped and more voluminous lesions than those of zona, occupying 
the territory of one or several nerve trunks, but only on a limited 
portion of this territory, accompanied by sensory disturbances, 
muscular atrophy, vasomotor disturbances, etc. Their essential 
characteristic is their repeated recurrence during several years. In 
one of my patients, vesicles reappeared five or six times a year at 
different points of the left hand, but always on the cutaneous terri- 
tory of the median nerve, throughout a period of ten years. 

Zosteriform eruptions, sometimes called chronic zona or recurrent 
zona, are observed after traumatism of the nerves, in peripheral 
neuritis, in diseases of the cerebrospinal axis, in syphilis, malaria, 
etc. 

Certain recurrent zonas might be classified equally well among 
the zosteriform eruptions, but the eruption is here far from being 
invariably unilateral. 

Treatment. — The local treatment of zona must be as simple as 
possible; avoiding moist dressings, poultices, salves, and ointments, 
which only serve to favor infection, leading to ulceration and scar- 
formation. It is advisable to empty the largest or confluent vesicles 
by pricking them with a flamed needle and to apply large amounts 
of bland, aseptic or sterilized powders, in order to favor desiccation. 
Occlusive dressings will relieve the painful sensations. 

Ulcerative or gangrenous lesions are treated in the usual way. 
The sometimes extremely distressing pains of zona require special 
treatment. Analgesic agents, aconite, gelsemium, antipyrin, 
pyramidon, exalgin, aspirin, are sometimes sufficient. Morphin 
injections must be avoided, if possible, on account of the danger of 
the morphin habit. Injections of a cocain solution, or sterilized 
air, along the course of the affected nerve, have been useful in a few 
cases. Radiotherapy and galvanic electricity are valuable measures 
in cases otherwise regarded as desperate. 

For the treatment of ophthalmic zona, the reader is referred to 
text-books on ophthalmology. 



CHAPTER IX. 
PUSTULES AND PUSTULAR DERMATOSES. 

The eruptive lesion known as a pustule is an epidermal elevation 
containing a purulent fluid. The cavity containing the pus may be 
situated in the epidermis, in the cutis, or in a follicle. A distinction 
is accordingly made between: 

1. Epidermic pustules which may be superficial when formed 
under the horny layer (example: impetigo); or deep, when they 
involve the basal layer of the mucous body and therefore leave a 
scar behind them (example: variola, ecthyma); (2) Dermic pustules, 
which are rare (example: miliary abscesses of the newborn; pustules 
of tuberculosis verrucosa); (3) Follicular pustules, which on the 
contrary are extremely common. The two last-named varieties will 
be discussed in other chapters. 

It would be correct and logical to reserve the name pustules for 
primary pustules, namely, those in which the lesion is suppurative 
from the start. In case of secondary suppuration of other eruptive 
lesions, terms should be employed like suppurative vesicles, purulent 
bullae, or suppurative papules, according to the condition present; 
but as this distinction is not always practicable; the words vesico- 
pustules, papuh-pustules, and tubercuh-pustules, are in common use 
to obviate this difficulty. 

Collections of pus in the hypoderm are not pustules, but abscisses 
or gummas. 

I' ust ales are of rounded, rarely oval configuration, more or less 
prominent, hemispherical or flattened, tense or flaccid, of a yellowish 
white or grayish color and surrounded by an inflammatory areola. 

Their dimensions are extremely variable, they may be punctiform, 
lenticular, or nummular; often they are small at first and undergo 
a centrifugal enlargement. 

It is usually easy to ascertain their more or less dee]) seat by means 
of direct examinations; if necessary — and it is advisable to do so — 
they must be punctured with a needle, in order to empty the con- 
tents, determine the thickness and constitution of the roof, the 
characteristics of the floor of the pustules, etc. 

The contents may be a more or less turbid and yellowish fluid, 
or consist of the creamy thickened substance known in former times 
as "laudable pus." Examined under the microscope, it contains 
chiefly polynuclears and plasma, 



PUSTULES AND PUSTULAR DERMATOSES 161 

The pustules do not persist a long time, they terminate by acci- 
dental or spontaneous rupture, or by desiccatioa. In both cases, 
they are followed by a yellow, brown or black crust, more or less 
thickened and irregular, covering an erosion, excoriation or ulcera- 
tion. 

The crusts — concerning which a few words are here in order 
from a general point of view — are concretions resulting from the 
desiccation of serous fluid, pus, or blood. Their thickness, regularity, 
more or less hard, greasy or friable consistence, their color ranging 
from light yellow to deep black and their adherence vary in extremely 
wide limits and are suggestive of their origin. 

Crusts form on wounds, erosions, traumatic or pathological excoria- 
tions of all kinds, on ulcerations and on old vesicles or pustules. In 
case of vesicles or pustules, the epidermis regenerates itself under- 
neath the lesion, extending from its periphery toward its center, 
eliminating it in the form of a crust; this mechanism is designated 
as eviction. 

Crusts are absent from tissue surfaces kept moist by mutual 
contact or by dressings. 

An essential difference exists between crusts made up of scales 
which are disintegrating epidermal layers; and hyperkeratoses, in 
which coherent horny collections are formed. 

A concretion is sometimes formed by epidermal layers alternating 
with layers of dried serum or pus ; these scaly crusts have a leaf-like 
structure and oily consistence; they are observed in a variety of 
conditions, notably in the eczematides. 

Pustular Dermatoses. — The dermatoses in which primary or 
secondary pustules occur are extremely numerous. 

1. In the first place the pyodermatitides are characterized by 
pustules from the start, originating on healthy skin and resulting 
from a cutaneous infection by pus cocci. Only the impetigos and 
ecthyma will be discussed at this time, leaving the description of 
the follicular pyodermatitides to the chapter on the Folliculoses. 

2. Several chronic infectious dermatoses are likewise pustular from 
the start, the pathogenic agent being capable of causing suppuration 
by itself alone (syphilis, tuberculosis, glanders, mycoses, etc.). 

3. Some eruptive fevers are pustular at a certain stage of their 
course; this is true for variola, vaccinia and sometimes varicella. 
Cutaneous diphtheria may exceptionally assume the complete 
appearance of impetigo vulgaris. These diseases need only be men- 
tioned in this connection. 

4. Some artificial dermatitides are, or may be, pustular from the 
start. Mercurial agents, fumes of tar and resinous plasters some- 
times give rise to erythemas with small scattered miliary pustules; 
thapsia, tartrate of antimony, croton oil, etc., produce lenticular 

11 



162 PUSTULES AND PUSTULAR DERMATOSES 

pustules; oil of cade and analogous products sometimes give rise to 
papulo-pustules. Certain toxidermas of internal origin are likewise 
pustular (iodides, bromides). The question arises if these chemical 
substances are pyogenic in themselves, or if, as seems probable, 
their action is limited to favoring the penetration and activity 
of the pyococci. The point has not yet been settled. A special 
chapter (XXIII) will be devoted to these artificial dermatitides. 

5. There still remain the secondarily and accidentally pustular 
dermatoses. When suppuration supervenes in the eczematous or 
vesicular dermatoses, this is evidently due to secondary infection 
by pyococci; secondary infection, however, has not been proved 
to be necessary in the bullous dermatoses, such as pemphigus and 
Duhring's disease, which includes a pustular variety. 

The secondary suppurations will be referred to in connection 
with each of the dermatoses in which they are met, so that this 
chapter deals only with the primary pyodermatitides and a few chronic 
infections. 

IMPETIGO. 

The name impetigo belongs to an affection characterized by 
inoculable and auto-inoculable purulent bulla?, appearing rapidly 
on the healthy skin, drying in crusts which are often yellowish and 
meliceric, the underlying epidermis being simply eroded and healing 
in a short time without leaving scars. 

Instead of developing on healthy skin, the suppuration and crusts 
which result from the drying of the pus may appear on a wound or 
on a pathological lesion, for instance eczema. These lesions are then 
said to be secondarily impetiginous, or better, impetiginized. 

The idea of a microbic external pyococcic origin of impetigo and 
impetiginization dates back nearly to the first days of the discovery 
of bacteria. As regards the responsible bacterial species, investi- 
gators are divided into two schools, some regarding streptococci 
and others staphylococci as the pathogenic agents. An important 
advance was made when Sabouraud established the fact that the 
different clinical forms of impetigo are referable to different organ- 
isms. 

There exist an impetigo streptogenes, an impetigo staphylogenes, 
and an impetigo vulgaris, in which the two microbic species are 
associated. 

1 . Streptococcic Impetigo or Impetigo of Tilbury Fox. — The primary 
eruptive lesion is a flaccid seropurulent blister, extending peripherally. 

The blister from a hemp-seed to half a hazel-nut in size, appears 
in a few hours on a faintly pinkish base. Its fluid may be serous, 
stringy and at first hardly turbid, but it soon becomes cloudy and 
is transformed into sero-pus. The roof of the blister is a thin 



IMPETIGO 



1G3 



opaline membrane, tense when the fluid is abundant, wrinkled and 
fluctuating in the opposite case. 

In consequence of evaporation, or surface extension, the bulla 
becomes flaccid if it has not been so to begin with. It may rupture, 
allowing its fluid to escape; or it may dry in a crust in its center, 
while it enlarges peripherally, or more particularly on one side, 
through detachment of the horny epidermis. At this stage the bulla 
is always surrounded by a congestive areola. Extensive or serpigin- 
ous bullse of this kind are met with measuring several centimeters 
in diameter. 

Finally, the lesion shrivels up to a yellowish or brownish crust 
covering a red erosion; it lasts from four to eight days, then becomes 
detached, leaving behind it a pinkish or purplish macule, which 
persists a fairly long time. 




Fig. 45. — Coexistence of impetigo of Tilbury Fox on the wrist, and impetigo of 
Bockhardt at the root of the thumb, in a case of 



The eruption is composed of a single bulla, or of more or less 
numerous bulla?, resulting from simultaneous or successive infections, 
or especially from spontaneous auto-inoculations. The bullse are 
often in different stages of development. 

Their seats of election are the face, especially around the mouth, 
the nose and ears, sometimes in the beard or on the scalp; further- 
more, on the extremities, affecting the hands and fingers, or the feet, 
where they originate from excoriations caused by the shoes, etc. 

The condition known as whitlow or subepidermic panaris, ["run- 
around"] is nothing more nor less than a bulla of streptococcic 
impetigo, derived from a fissure or a hang-nail, and having a ten- 
dency to extend around the nail. 

Other tegumentary regions are more rarely affected, except in 



1G4 



PUSTULES AND PUSTULAR DERMATOSES 



ease of gross neglect, traumatism, or scratching. In scabies, for 
example, complication with the impetigo of T. Fox is common, 
although less frequent than staphylococcic complications. 

In the impetigo of T. Fox the glands belonging to the affected 

regions are usually swollen and tender, especially when the eruption 
is accompanied by lymphangitis; the absence of protective dressings, 
fatigue, overwork and general debility, favor this complication. 
These cases are associated with pain, fever, digestive disturbances, 
prostration; the local infection may also lead to a grave but for- 
tunately rare general disease, a streptococcic septicemia. 

In contradistinction to other forms of impetigo, the impetigo of 
T. Fox shows no predilection for a given age or sex. 




A K4HMANSKI 

Fig. 4fi. — Histology of impetigo of Tilbury Fox. Border of a very recent bulla 
of the ear. The cavity is the result of splitting of the epidermis at the level of 
the granular layer. The bulla which is subcorneal, contains a coagulated fibrino- 
albuminous fluid, detached epithelial cells, and a small number of pus cells. The rete 
which is not deformed and the edematous papillary body are seen to contain a few 
wandering cells which are beginning to make their appearance. X 90. 



The affection lasts from three to eight days under suitable treat- 
ment and may persist for weeks or months under the opposite 
conditions, or when circumstances are present favoring auto- 
inoculations. 

The 'pathological lesion consists of a bullous elevation of the horny 
layers by a fluid composed of blood-plasm and leukocytes in vari- 
able proportion. The mucous body and the papillary body are 
infiltrated with more or less numerous wandering cells (Fig. 4(i). 

The demonstration of the streptococcus, the primary pathogenic 
agent, is not easy in sections; it is made by cultures in ascites-broth 
in pipettes, according to Sabouraud's method, or by making numer- 
ous streak-cultures on agar slants with a single platinum wire 



IMPETIGO 



165 



carrying a small amount of material, as recommended by Lewan- 
dowsky. 

2. Impetigo Vulgaris. — This is the most frequent form of impetigo 
and is chiefly observed in children of all ages, especially from two to 
seven years, or in adults with a delicate skin. It is highly contagious 
and of polymicrobic origin. 

It was formerly considered as the typical impetigo whose chief 
characteristic was said to be the thick, extensive, coarse, yellow 
crusts, which were described as meliceric on account of their resemb- 
ling dried honey. The popular term of milk crusts is applied to 
this impetigo as well as to impetiginized infantile eczemas and 
seborrheal crusts, etc. 




Fig. 47. — Impetigo vulgaris of the face in a child aged two years. 



A crust can never be characteristic of a dermatosis as it is always 
merely a secondary lesion. On closely following a case of impetigo 
vulgaris, the initial lesion will usually be found to be a bulla of T. 
Fox impetigo; this rapidly becomes purulent, dries to a crust at its 
center while it extends at its periphery and in this way gives rise to 
circinate crusted lesions. At the circumference appear either similar 
lesions, or staphylococcic pustules, such as will be described further 
on. The glands are usually enlarged. 



100 



PT'STl'LES AM) PUSTULAR DER MATOSES 



The eruption often lakes its origin near the nostrils, following 
coryza; near the mouth, following fissures of the lips or "perleche" 
(Fig. 17 i, near the eyelids in the case of conjunctivitis; on the 
cars, in case of suppurative otitis; in the occipital region of the 
scalp in children and women having head lice; on the beard; 
where it is inoculated by means of the razor (Fig. 48). [In my 
experience impetigo in children is almost invariably associated with 
pediculosis capitis.] 









4 


K 


V 



Fig. IS. — Impetigo vulgaris, derived from inoculation with a razor. 



Impetigo larvalis is the term applied to an eruption which covers 
the fa.ee like a mask; impetigo granulata affects the seal]) or the 
beard, giving rise to crusts whose fragments adhere to the hairs. 
Other varieties have been described as impetigo sparsa, figurata, 
etc. 

It is not nearly so important to fit the exact descriptive term to the 
objective appearance as to determine if the impetigo is primary or 
secondary in character. As a matter of fact, it may point the way to 
an infection of the mucous membranes or body orifices as stated 
above, or complicate an eczema,, a hum, or some traumatic der- 
matitis, scabies, lupus ( Fig. 169), syphilides, etc. These impetiginized 



IMPETIGO 167 

eruptions are sometimes not clearly recognized unti 1 after several 
days of treatment. 

The microbes of impetigo vulgaris may become implanted and 
vegetate wherever they find a point of entrance. 

The term impetigo contagiosa has no special significance and 
applies to cases where genuine epidemics are observed in families 
or schools. 

Impetigo has a marked tendency to recurrences which are ex- 
plained by the persistence of virulent pyococci in the lesions, called 
by Sabouraud the chronic remains of impetigo, such as redness and 
crust-formation behind the ears, around the nostrils, perleche, 
blepharitis and styes, and even pityriasis simplex (dry seborrhea). 
These chronic infections and the adenopathies dependent upon 
them enter into the clinical picture of scrofula. 

Impetigo of the Mucous Membranes. — When astride the free 
border of the lips, impetigo is crusted in its cutaneous portion and 
diphtheroid in its mucous portion. Sevestre and Gaston have 
described an impetiginous stomatitis, the characteristics of which 
are as follows: Diphtheroid spots of a yellowish white color; 
imbedded and incorporated in the epithelium, scattered over the 
mucosa of the lips, the cheeks, sometimes on the tongue and palate, 
never on the isthmus of the pharynx or in the throat; usually, 
ulceration of the alveolar margin; a low degree of contagiousness; 
ordinarily associated with impetigo of the face. Failure to recognize 
this affection may result in the most annoying errors in diagnosis. 

Certain coryzas, pyococcal blepharoconjunctivitis, even phlyc- 
tenular conjunctivitis, may, strictly speaking, be interpreted as 
impetigo of mucous membranes. 

3. Staphylococcic Impetigo, or Impetigo of Bockhardt. — This is char- 
acterized by a primary pustule, containing yellowish creamy pus, 
often centered by a hair and surrounded by a congestive areola. 
The lesion has the size of a pin-head to that of a large lentil; the 
pus collects under the horny laver, elevating and distending it 
(Fig. 49). _ 

A perifollicular seat is common but not constant and Bockhardt's 
impetigo has so many points of contact with impetigo vulgaris that 
it must be grouped with the latter rather than with the folliculitis. 
The pustules are usually multiple, often very numerous and are 
grouped in one or more regions whence they may spread. The 
eruption has no preference for special parts of the body, but develops 
at any point where the horny layers have ceased to oppose an efficient 
barrier against the penetration of the pyococci. This occurs in 
cases of traumatism, scabies, chemical dermatitis, or epidermal 
maceration through the application of a simple poultice or plaster. 
Preexisting suppurations, dirt, pruritus and neglect, constitute 



168 PUSTULES AND PUSTULAR DERMATOSES 

conditions favorable to its development. A youthful age, lymphat- 
ism, overexertion, etc., seem to act as predisposing factors. 

The pustules of staphylococcic impetigo appear in a few hours, 
being more resistant than those of the preceding forms; they rupture 
late or accidentally. The pus is then thickened into yellow crusts. 
Unopened pustules shrivel up first in the center and are cast off" by 
eviction. 

Bockhardt's impetigo is accordinglv merely one of the elementary 
forms of cutaneous staphylococcia, the most superficial and most 
benign type of the disease. There exist intermediary forms between 
the impetigo of Bockhardt and the more or less deep folliculitides 
(Plate II). Combinations with other forms of staphylococcia 
frequently occur. 






• i ... 



Fig. 49. — Histology of the pustule of Bockhardt's impetigo. The cavity of the 
pustule is situated within the rete; its roof is formed by the horny layer, doubled in 
places by the granular layer; its floor is represented by the lower strata of the rete, 
which are seen to be crowded and flattened. The oblique section of two downy 
hairs may be seen floating in the purulent contents of the pustule. X 60. 

A bullous form of impetigo, generally known under the name of 
epidemic pemphigus of the newborn will be discussed further on p. 178. 

The affection described under the name of infantile vacciniform 
dermatitis by Hallopeau, vacciniform herpes, by Founder, is probably 
merely a variety of impetigo. It appears in the form of erythematous 
spots, the epidermis of which is rapidly raised by a turbid fluid, 
with central umbilication. It is observed in neglected infants, 
especially around the ano-genital region. The eruption may simu- 
late varicella. 

Treatment. Every practitioner should know how to treat impetigo. 
Whether it be primary or secondary, the treatment is the same, but 
in the latter case, after the complication has been removed, the 
original dermatosis will require attention. 

In the first place, the treatment must be local. A fundamental 
rule is to get rid at once of all crusts or active inflammation that 



ECTHYMA 169 

may be present. This will be accomplished in a day or two by means 
of moist softening or slightly antiseptic dressings, sprays or starchy 
poultices, to be applied cold. At each dressing, at least three times 
in twenty-four hours, antiseptic or astringent lotions must be applied ; 
the solution which for some time has achieved, or rather resumed 
general and well deserved favor is Alibour water, the formula of 
which dates back to the reign of Henri IV. As soon as the surfaces 
are cleansed, pastes or salves made with boric acid, camphor, white 
precipitate and especially yellow precipitate are indicated. A mer- 
curial plaster is serviceable for the isolation of scattered lesions of 
impetigo. Camphorated lotions or ichthyol pastes help to prevent 
recurrences. 

Internal treatment, contrary to a commonly held view, is by no 
means indispensable, and must never be considered as sufficient by 
itself alone. It may be necessary sometimes to prescribe cod-liver 
oil, iron iodide, arsenic, or the ferments and yeasts. Dietetic 
measures, residence by the seaside, or mineral springs, influence 
only the general condition. 

ECTHYMA. 

The meaning of the term ecthyma has undergone some slight 
changes, according to different authors and at different times, so 
that it is somewhat difficult to separate ecthyma from the impetigos, 
from rupia of the older writers and from ulcers of the skin. 

Ecthyma actually represents a pustulo-idcerative pyodermatitis; 
namely, a microbic dermatitis of external origin (XXVI) like impetigo, 
beginning like the latter with a pustule, but differing from it by the 
greater dimensions of its lesions and especially by their ulcerative 
character. The ulceration is frequently covered by a crust, which 
may be rupioid. Ecthyma always leaves a scar behind it. Like 
all other pyodermatitides, it is inoculable and auto-inoculable. Its 
special clinical characteristics are referable to a peculiar virulence 
of its pathogenic agents, or to a deeper inoculation of these agents, 
favored by some tissue lesion or preliminary affection, or finally 
to the soil on which it develops. 

When the mode of formation of an ecthyma lesion can be watched, 
it is seen to begin with a pustule, usually flattened and with turbed 
contents, like the impetigo of T. Fox, more rarely tense and con- 
taining a creamy pus, like the impetigo of Bockhardt. 

This pustule, having very rapidly reached nummular dimensions, 
shrivels up into a more or less thickened, yellowish or brown, 
adherent crust, which is flattened or protuberant, sometimes 
ostreaceous, surrounded at first by a bullous collar and always by 
a congestive halo. When this crust falls off or is removed by means 



170 PUSTULES AND PUSTULAR DERMATOSES 

of the dressings, it is seen to cover a rounded or oval ulceration, 
more or less deeply encroaching upon the derma. Its borders are 
regular and clean-cut; the floor is red or pultaceous, sloping toward 
the center in the stage of advance, granulating in the stage of repair; 
the secretion consists of viscid or clotted brownish and blood-tinged 
pus; the base is not indurated, but sometimes diffusely edematous. 

After lasting two or three weeks in favorable cases, but much 
longer under bad conditions, the ulceration heals through granula- 
tion and cicatrization; the scars are often pigmented at their border. 

Glandular enlargement, lymphangitis, phlebitis, abscesses, are rare 
complications. 

The lesions are usually multiple, rarely very numerous and, as a 
rule, of different ages, having originated from successive auto- 
inoculations. 




Fig. 50. — Eethyma oi the leg. The lesions have been deprived of their crusts and 
cleansed by means of moist dressings. 

Ecthyma has its .scat of election on the lower limbs (Fig. 50); the 
buttocks and the back are less frequently affected, the part played 
by congestion and circulatory stasis is therefore very evident. 

Ecthyma is usually observed only during the first half of life; it 
affects overstrained, weakened, scrofulous, diabetic, varicose, or 
alcoholic subjects; not uncommonly, it is induced by scratching 
due to uncleanliness, or by scabies and lice. Ecthyma has figured 
to a great extent among the soldiers in the trenches. 

There are no valid reasons for distinguishing a cachectic ecthyma, 
;i scrofulous ecthyma, etc., nor is it correct to describe as scabies- 
ecthyma all the pyodermatitides complicating the itch. The anti- 
quated terms of syphilitic ecthyma and syphilitic rwpia, to designate 
ulcerative syphilides, are altogether objectionable. 



ECTHYMA 



171 



In the presence of unfavorable nutritional conditions and local 
circulatory disturbances, an ecthyma pustule may become the 
starting-point of a leg-ulcer. 

The pathological anatomy of ecthyma, in the ulcerative stage, 
shows a deep and remarkably distinct ulcer, bordered by a thin 
layer of leukocyte infiltration; apparently resulting from molecular 
disintegration and not from sloughing. The pus contains tissue- 
debris, elastic fibers, altered red corpuscles, and various cocci. 

Ecthyma is ascribed by authors either to the streptococcus or to 
a microbic association. Vidal's statement that experimental inocu- 
lation of ecthyma-pus will produce this dermatosis, but no other pyo- 
dermatitides, is not strictly correct; however, the ecthyma-eruption 




Fig. 51. — Erythema terebrans of the back in a child a,ged two and a half years. 



is not infrequently pure and is not associated with other pyococcic 
manifestations. According to recent investigations of Lewandowsky 
ecthyma seems to be a simple streptococcia, closely related to the 
impetigo of T. Fox and with a slight tendency to become secondarily 
infected. 

The name ecthyma terebrans is applied to a pustulo-ulcerative 
eruption in children, rare and rather obstinate, occupying the 
buttocks, thighs, and back progressing by contiguity, in the form 
of lenticular, sometimes vacciniform or even gangrenous pustules 
(gangrenous varicella of English and American writers). These 
pustules become confluent and give rise to enormous polycyclic 



172 PUSTULES AND PUSTULAR DERMATOSES 

ulcerations, with festooned margins, a grayish floor and dusky cir- 
cumference, leaving honey-combed cicatrices (Fig. 51). This grave 
eruption lias been observed especially in weakly newborn infants 
suffering from diarrhea (Neumann's ecthyma of cachectics) ; excep- 
tionally also in older children and even in adults. According to 
Bosellini and others, the affection is due to the bacillus pyocyaneus. 

The treatment of any ecthyma of the lower limbs requires rest, in 
bed, moist applications to loosen the crusts, followed by lotions of 
Alibour water or peroxide water; the ulcers are then dressed with a 
salve or paste of yellow oxide, or an absorbent or antiseptic powder 
may be used, such as dermatol, aristol, etc. Touching with a silver 
nitrate solution may prove useful. During the stage of repair, the 
ulcerations are advantageously covered with red oxide ointment or 
balsam of Peru. 

General treatment is not usually necessary; regulation of the 
patient's hygiene will suffice. 

PUSTULES OF THE INFECTIOUS CHRONIC DERMATOSES. 

Syphilis, tuberculosis, glanders and certain mycoses and tropical 
diseases may give rise to pustular .syndromes. 

Syphilis. — There exist syphilides which are only apparently 
pustular; no drop of pus can be obtained by puncturing them with 
a needle. Such syphilides are known as papulo-crusted or impeti- 
ginous syphilides. They are generally mixed in with a crop of 
lenticular papules, of which they are merely a variety; or they may 
predominate in a given eruption. 

The more or less profuse eruption is irregularly scattered over the 
trunk, limbs, face and scalp; it consists of round lenticular crusts, 
brownish-yellow, swollen, slightly adherent, sometimes exuberant, 
ostreaceous or rupioid (see Fig. 94), which cover a papule with a 
smooth moist surface, instead of an ulceration, as one might be led 
to believe. 

Precocious malignant syphilides of the ecthymatoustype begin, before 
undergoing ulceration, with a large papule the epidermis of which is 
raised by pus; this hardens into a crust; under this crust and at its 
periphery the ulceration develops and progresses. 

Tuberculo-crusted syphilides, which are apt to be circinate, are only 
transitorily pustular; they belong rather to the tuberculo-ulcerative 
eruptions. 

Tuberculosis. — Tuberculous ulcers begin as very small papulo- 
pustules which open and coalesce. In tuberculosis verrucosa, deep 
pustules are almost regularly seen, the contents of which can be 
squeezed out by compressing the vegetating patch between the 
fingers. 



PUSTULES OF INFECTIOUS CHRONIC DERMATOSES 173 

There exists a form of lupus exedens which is entitled to the name 
of pustular lupus. 

It is especially important to keep in mind the very frequent 
occurrence of impetiginous changes in eroded lesions of lupus; 
fungoid tubercles, open scrofulous gummas, or atypical tuber- 
culous ulcers becoming covered with yellow or brownish crusts. 
A diagnosis of impetigo or ecthyma must be carefully excluded in 
such cases. In the absence of information regarding the develop- 
ment, it suffices to detach or otherwise remove the crusts, to bring 
into view the grave underlying lesions. 

Papulo-necrotic tuberculides are genuine pustules at a certain stage 
of their development. They are generally recognized by their very 
peculiar course and sometimes by their topographical distribution. 

Glanders. — One of the clinical features of acute glanders consists 
in a pustular eruption resembling that of smallpox. The round, 
non-umbilicated pustules form rapidly, occupying especially the 
face, the mucous membranes and the limbs; they rupture later on, 
leaving extensive ulcerations. The general symptoms suggest the 
diagnosis which must be confirmed by bacteriological methods. 

The mycoses (sporotrichosis, etc.), Leishmaniasis (Biskra boil or 
button) and verruga Peruviana may give rise to pustules at their 
onset, or in the course of the disease (XXIX). 



CHAPTER X. 
BULLAE AND BULLOUS DERMATOSES. 

BuiJLffi or phlyctenes (blebs) are eircumscribed elevations of the 
epidermis containing an ordinarily clear and serous, sometimes 
turbid or hemorrhagic fluid; when the fluid consists of pus, the lesion 
becomes a purulent bulla. 

Hulhe differ from vesicles by their generally larger size as well as 
by their structure and mode of formation. Their shape is round or 
oval and their size varies from that of a pin-head to that of a hen's 
egg or larger; their surface is tense or flaccid. They terminate 
through rupture, suppuration, or simple desiccation; in all these 
cases, they are followed by a crust of variable color and thickness 
according to the character of the exudate, covering a more or less 
dee]) erosion. The crust becomes detached in five to fifteen days, 
leaving almost invariably a temporary red or brownish macule in 
its place. 

Blebs or bullae do not result from a progressive process, like vesicles, 
but from a genuine splitting of the epidermis. Their cavity is there- 
fore unilocular from the start; when the fluid contents have been 
emptied, through pricking or tearing the bulla, it collapses entirely. 

Two processes are concerned separately or jointly in the formation 
of bulla?. Most frequently they follow a local dermic edema, the 
edematous fluid under high pressure filtering through the Mal- 
pighian layer, until it is arrested by the horny layer which it raises 
by accumulating below it. This results in the production of a 
superficial or .subcorneal bulla (Figs. 46 and 58). 

In other cases, the still more sudden rush of fluid detaches the 
epithelium as a whole, giving rise to a deep or subepithelial bulla 
(Fig. 56.) 

In ease of the second mode of bleb-formation, the mutual cohesion 
of the cells of the mucous body is pathologically diminished; the 
intercellular Glaments have lost their resistance; they separate under 
the influence of the slightest excess of pressure of the intercellular 
plasma. This abnormal condition is designated as acantholysis, 
after Auspitz, and the resulting bullae are known as arantholi/tic 
bulla: 

Bullous Dermatoses. -The group of bullous dermatoses is very 
extensive and very complex. The older writers interpreted all 



ACCIDENTALLY BULLOUS DERMATOSES 175 

bullous eruptions as pemphigus, a circumstance which resulted 
in extraordinary and persistent confusion. This designation is now 
reserved for a small minority of these cases. The following eruptions 
do not belong under the heading of pemphigus: 

Traumatic bulla', or blisters, produced by strong pressure [or 
friction] ; and those which result from burns, or from the action of 
caustics and vesicants. These are artificial external dermatitides 
of bullous form and will be discussed further on (XXIII). 

Bullae, occurring as epiphenomena in the course of definite nervous 
or infectious diseases, such as syringomyelia, leprosy, purulent 
infection, etc. 

Accidentally bullous dermatoses, such as erysipelas, eczema, 
dysidrosis, ichthyosiform hyperkeratosis; mention must be made 
of bullous urticaria, bullous polymorphous erythema or hydroa, 
bullous syphilides and bullous toxicodermas of internal origin. 

External microbic bullous eruptions, which according to Unna are 
all entitled to the name of impetigo. Although it remains doubtful 
if certain pathological varieties should be grouped under this heading 
rather than with acute pemphigus, this seems to be justifiable as 
regards the so-called epidemic pemphigus of the newborn and of 
adults, which is really a bullous impetigo. 

Eliminating these forms there are left some essentially bullous 
affections, of undetermined but decidedly variable type, which are 
designated as pemphigus, and include: (1) Pemphigus acutus 
febrilis gravis. (2) Recurrent polymorphous pemphigus, or Duhring's 
dermatitis; (3) Pemphigus chronicus; (4) Pemphigus foliaceous; 
(5) Pemphigus vegetans; (6) Pemphigus congenitalis. So-called 
pemphigus hystericus will later be considered in a few lines. 

Accidentally Bullous Dermatoses. — Some of these require special 
mention on account of the difficulties of diagnosis and interpreta- 
tion which they may occasion. 

Bullous Urticaria. — This is a rare variety of urticaria in which all 
or some of the lesions become crowned with a bullous prominence, 
followed by a crust. The eruption may be chronic or recurrent. 
In view of the pruritus and the erythematous base of the bullae, this 
affection may be confused with Duhring's dermatitis, from which 
it is distinguished by its irregular distribution and the absence of 
true polymorphism, each bulla originating on .in urticarial wheal. 
Sometimes, it is possible to demonstrate a tendency to urticaria in 
the patients. 

Bullous Polymorphous Erythema or Hydroa. — In certain cases of 
polymorphous erythema, localize 1 as usual on the back of the hands, 
on the wrists, elbows, knees, on the face and especially on the 
forehead, etc. (Fig. 52), some lesions or most of them may become 
the seat of vesicles or of tense bullae which when pricked with a 



176 



BULLM AND BULLOUS DERMATOSES 



pin void a lemon-yellow or reddish-fluid. The bullae occupy the 
entire surface of the papular elevations or only their center; some- 
times they are situated at the periphery. 




Fig. 52.— Erythema bullosum; first attack, in a gir] aged eleven years. (The buccal 
mucosa were affected a1 several points. 




I ,,,. 53 Erythema bullosum of the variety hydroa vesiculareof Bazin, or herpes iris 
of Bateman. 



The name of Bazin's hydroa, or herpes iris of Bateman, is applied 
to a variety in which the lesions, consisting of a small bulla or central 
crust, surrounded by a bright red or purplish disk, a vesiculo- 
bullous circlet and narrow erythematous border, present a striking 
cockade-like arrangement (Fig. 53). 



BULLOUS TOXICODERMAS 111 

The eruption often affects also the lips, the mouth, the tongue, 
the pharynx and the other mucous membranes. 

Hydroa biiccale, characterized by bullous elevations which are 
rapidly replaced by very painful nummular deep red or diphtheroid 
erosions, simulates and is sometimes mistaken for mucous patches. 
In exceptional cases it may be accompanied by fever and infectious 
symptoms, with severe visceral complications. 

Polymorphous bullous erythema usually lasts from two to five 
weeks; it may be prolonged beyond that time by successive erup- 
tions, or it may recur at variable intervals in a number of attacks. 
This tendency to relapse and the unusual severity of the sensations 
of itching and heat, in some cases result in so close a resemblance 
to Duhring's disease as to render the diagnosis necessarily doubtful. 

Bullous Syphilides. — The eruption known under the name of 
syphilitic pemphigus is met with on the palmar and plantar regions 
of newborn children with congenital syphilis. It consists of papular 
lesions of a purplish or coppery hue, discrete or confluent, the epi- 
dermis of which is raised by a turbid or blood-stained fluid; the 
dimensions of the bullae vary from those of a hempseed to those of a 
large bean, but confluence in extensive patches may occur. 

In two or three days, these bullae dry into crusts, covering an 
ulceration. Their fluid contents and especially the fluid obtained 
by scraping their floor, contain enormous numbers of spirochetes. 
It is exceptional for the eruption to become generalized under the 
same form; but a few aberrant bullae, or syphilides of another type, 
may be found in other portions of the body. 

This eruption, the only syphilide assuming a bullous form, appears 
almost exclusively at the time of birth, a few days before or after. 
It is pathognomonic. 

Bullous Toxicodermas. — Aniipyrin bulla? represent a transforma- 
tion of the erythematous patches produced by antipyrin in some 
individuals (Fig. 145). They originate abruptly in any region, 
especially the genitals and the mouth, reappearing with each 
repeated administration of the drug and leave a brown discoloration. 

Iododerma bulbsum is a rare affection produced by potassium iodide 
or its congeners; the lesions may be clear, distinctly pemphigoid bullae, 
of rapid development, located especially on the neck or in the folds 
(Fig. 146); or the condition may consist of very rapidly purulent 
and extensive bullae, the center of which becomes fungoid arid 
crusted, situated in very variable numbers on the face, the mouth, 
the limbs or the trunk; they suggest the fungoid syphilides or more 
particularly pemphigus vegetans. This eruption may persist during 
several weeks, especially if the medication is continued. 

Bromides, arsenic, etc., are likewise capable of causing the' 
appearance of blisters. 
12 



178 BULLJE AND BULLOUS DERMATOSES 

BULLOUS IMPETIGOS. 

The impetigos are pyodermatitides the eruptive lesion of which 
is a pustule or a purulent bulla; they are all more or less contagious. 

A somewhat distinct bullous type is generally described under the 
name of epidemic pemphigus of the newborn. It is encountered in 
nursing infants, in asylums, hospitals, or even in families— more 
rarely in adults — in the form of an acute eruption of clear tense hemi- 
spherical bulhe, the size of a lentil to that of a nut; from one to about 
thirty in number. They occur in the folds of the neck, trunk and 
limbs, rarely on the face, but are never encountered in the palmar 
and plantar regions. 

These bulla? supervene in healthy or in marasmic children, in 
successive crops, in the form of red spots which very rapidly become 
blisters; at the end of a few hours the bulla ruptures and the thin 
crust falls off in a few days. Recovery is the rule; exceptionally , in 
weakened patients, symptoms of severe general infection have been 
noted. 



3 i» 



Fn;. .54. — Impetigo bullosum in a child aged sixteen months. 

This affection is highly contagious. Vida] has shown that it is 
possible to inoculate and auto-inoculate the fluid of the bulhe. It 
contains, according to Peter, the Staphylococcus aureus, some albus 
and a special diplococcus which is by several authors considered the 
cause of the disease; perhaps, in addition, a streptococcus. The 
Staphylococcus aureus is regarded as the real pathogenic agent by 
Dohi and Jadassohn. 

Bullous impetigo is sometimes observed also in older children 
(infantile pemphigoid of Jadassohn) in combination witli various 
pyodermatitides (Fig. 54). 

Confusion must be avoided with varicella, generalized vaccinia, 
impetigo vulgaris and the bullous syphilides. However, the features 



RECURRENT PEMPHIGUS OR DUHRING'S DISEASE 179 

of these various eruptions are usually sufficiently distinct to guard 
against errors in diagnosis. 

The treatment consists in extreme cleanliness, absolute hygiene 
and isolation of the patient. Locally, washing with Alibour water 
will suffice, and dressings with a bland powder, an oil and lime 
liniment, or yellow precipitate salve. 

PEMPHIGUS ACUTUS FEBRILIS GRAVIS. 

This is a systemic infectious disease, with a bullous eruption, 
studied by Nodet (1880), George Pernet (1895-1896) and Brocq; 
it affects almost exclusively butchers, sausage-makers, pork- 
choppers, tanners, cooks, etc., namely persons who handle dead 
animals. The infection usually follows upon some injury of the hand, 
manifesting itself, abruptly by chills, prostration, vomiting or diar- 
rhea, delirium or depression and a temperature of 40° (104°). The 
eruption appears twenty-four to forty-eight hours later, in the form 
of tense bullae with yellowish or hemorrhagic contents; originating 
on red spots and almost invariably undergoing rupture. It occupies 
the neck, the chest, the limbs or the entire body; discrete at first, it 
soon becomes confluent and may involve the mucous membranes. 
Death results in over three-fourths of the cases, at the end of one 
to three weeks, under typhoid symptoms, albuminuria, various 
congestions, etc. Recovery takes place through gradual subsidence 
of the symptoms in three to six weeks. 

The anatomical lesions of acute pemphigus and its pathogenic 
microbe are unknown. The condition evidently represents a 
variety of septicemia. 

The indications are to combat the infection by means of quinine, 
collargol, serum injections and intestinal irrigation, and to support 
the organism by all possible means. Moist or oily dressings, cotton 
wraps, and so forth serve to relieve the burning sensation which is 
often extremely distressing. 

RECURRENT PEMPHIGUS, DUHRING'S DISEASE OR 
POLYMORPHOUS DERMATITIS (BROCQ). 

A well-characterized dermatosis in typical cases was described 
by Duhring, in 1884, under the name of dermatitis herpetiformis. 

This affection, which the Vienna School confused with chronic 
pemphigus and multiform erythema, was designated by the old 
French writers as pemphigus with small bulla?, or pruriginous 
pemphigus, or "arthritide bulleuse" (Bazin). English authors, 
following Tilbury Fox and Colcott Fox, prefer the name of hydroa 
herpetiforme. 



180 



BULLM AND BULLOUS DERMATOSES 



In the opinion of Brocq, who thoroughly investigated this ques- 
tion the disease is entirely distinct from pemphigus; and since the 
eruption is far from being invariably herpetiform, he extended the 
scope proposed by Duhring and established a group of painful poly- 
morphous dermatitides [dermatites polymorphes douloureuses] com- 
prising numerous forms or varieties. This view is becoming more 
and more generally adopted. 

Personally, like many others, I put together under the name ot 
Duhring's disease all the varieties of the disease, of which the 
American author originally described only the form with small 
vesiculaT lesions. Instead of attempting to multiply the clinical 
types, according to the dimensions of the bullae, etc., I shall endeavor 
to map out a general view, in the following description: 




1 ig. 55. 1 termatitis 



of Duhring. Anterior aspect of arm and right axilla. 



Symptoms. E 
disease: 1 Tfc 



,,■ clinical features arc characteristic of Duhring's 
polymorphism of the eruption; 2 painful phe- 
nomena, usually very pronounced: (3 the usual preservation of 

] general health; 1 the tendency to recurrences. [The tetrad 

of symptoms which seem most characteristic are: The polymor- 
phic. i of the lesions; their more or less marked herpetic grouping; 
the pruritus and the tendency to recurrences. Sensations of pain 



RECURRENT PEMPHIGUS OR DUE RING' S DISEASE 181 

are noted in the minority of the cases in my experience.] The onset 
is marked sometimes by the eruption, sometimes by a preliminary 
pruritus. 

1. The eruption is polymorphous and presents itself under very 
variegated aspects (Fig. 55); it often covers a large portion of the 
limbs and the body. It is composed of erythematous patches, 
papules, vesicles, bulla? and sometimes pustules. 

The multiple spots or erythematous patches are often urticarial 
and marginated ; in the same case, they may have nummular dimen- 
sions or resemble large polycyclic surfaces; more rarely, simple 
papules are met with. 

A tendency to bleb-formation manifests itself early through the 
appearance, on the surface of the patches, of sometimes uniform, 
herpetiform, grouped or scattered vesicles, often arranged as a 
border; or bulla? may be seen, from the size of a pea to that of a nut, 
with clear or rapidly purulent contents. Vesicles or bullae may also 
originate in the healthy skin in the vicinity of the patches, or they 
may swarm out to a distance. In a general way, the figured erythe- 
matous patches, interspersed with herpetiform vesicles or bulla? are 
the most characteristic feature. 

The most frequent initial localization is on the limbs, especially 
on the forearms; but the eruptioa may start anywhere. It proceeds 
by enlargement of the primary lesions and the production of new 
lesions, appearing every two or three days in small numbers, or in 
large crops every five to ten days. The duration of each lesion is 
limited, however. The erythema fades; the vesicles and bulla? 
burst through scratching and are replaced by red surfaces, raw or 
covered with crusts; the latter fall off and leave pigmentary macules, 
very rarely cicatrices. Lesions of different age are thus present at 
the same time. 

As a rule, the eruption is decidedly symmetrical. It affects espe- 
cially the limbs, the buttocks, the chest, etc., but has a tendency to 
cover the entire body; possibly the face, the scalp, the palms of the 
hands and the soles of the feet are less frequently involved. When 
the last-named regions become keratotic, arsenic medication may 
possibly be responsible. 

The mucous membranes, more particularly the buccal mucosa, are 
affected in nearly one-half of the cases; the lesions here resemble 
those of hydroa. [Involvement of the mucosa is by no means so 
frequent in this country as in the author's experience.] 

An endless number of eruptive varieties might be described; but 
it is enough to point out that the predominant lesion may take the 
form of erythema, or of herpetiform vesicles, these being the cases 
which Duhring had in mind, or of bulla?, which led Kaposi and his 
school to see in this affection merely a modified form of pemphigus 



182 BULLM AND BULLOUS DERMATOSES 

vulgaris. American and English writers have described a pustular 
variety, with pustules from the onset. Sometimes the bullae are 
extensive and plainly vegetative in character. 

Cases are observed in which the eruption is localized in a certain 
region of the body; other cases in which polymorphism is absent, 
notably in children or youthful individuals, vesicles or bullae occur- 
ring exclusively. In still other cases, on the contrary, nothing is 
seen but patches of marginate erythema, incessantly recurrent and 
pruritic, with very scanty vesiculation. 

2. The painful phenomena are one of the fundamental charac- 
teristics of Duhring's disease, but cannot be considered as constant 
and pathognomonic, as claimed by Besnier and Brocq. They con- 
sist of sensations of itching, heat, burning or acute pain. They may 
precede the eruption by a few days, but are especially liable to 
accompany each crop, with exacerbations in the evening and during 
the night. Although usually of moderate severity, the patient's 
sufferings may reach an intolerable degree, and have even led to 
suicide. 

3. The general condition, notwithstanding the very extensive 
cutaneous lesions, the pruritus and the insomnia remains remarkably 
good, the patients eating and digesting well and losing no flesh. 
In exceptional cases attacks of diarrhea or a slight rise of tempera- 
ture have been noted. The visceral complications (pulmonary and 
especially renal) which have been said to occur, are probably 
referable to intercurrent diseases. 

4. The course is variable. Attacks as described above last from 
six weeks to three months, sometimes six months or a year. But 
they are often followed by a subsidence, or even a return to normal, 
lasting several weeks, several months or even a year or longer, 
then a new attack supervenes, and so on at irregular intervals, up 
to ten or fifteen times. Finally, the attacks become milder and 
ultimately cease. The proportion of recoveries can hardly be 
specified. 

The disease is sometimes prolonged until death, which in rare 
cases is due to pemphigus foliaceus or to cachexia: much more fre- 
quently to an intercurrent affection. Hence, although Duhring's 
disease must tie considered as very grave, this is rather on account of 
its long duration, the suffering caused by it and the interference with 
social relations which it entails than on account of a risk to life. 

Its practically constant tendency to proceed not only in small 
distinct or continuous crops, but in attacks or recurrences separated 
by periods of subsidence, seems to me to constitute one of its most 
characteristic features. 

Cases with identical symptoms are observed, however, in which 
the disease is restricted to a single attack, mild or severe. These 



RECURRENT PEMPHIGUS OR DUH RING'S DISEASE 183 

may be classified under polymorphous erythema. Brocq admits a 
group of acute non-recurrent painful polymorphous dermatitis. 

Pathological Anatomy. — The erythematous plaques are composed 
of congestion, with well-marked edema and abundant diapedesis 
in the papillary body; eosinophile cells are present in large numbers. 

The bullse form as the result of subepidermic rupture (Fig. 56), 
sometimes subcorneal rupture. Occasionally they result from 
enlargement of interstitial vesicles. Deep or superficial bleb- 
formation is accordingly observed in this disease together with 
vesiculation. 

The fluid of the vesicles or bulla? contains at first a large pre- 
ponderance of eosinophiles, in a proportion of 30 to 95 per cent. 
The blood usually shows from 12 to 15 eosinophiles in 100 white 
corpuscles, sometimes only 5 per cent., exceptionally up to 30 per 
cent. There are no constant visceral or nervous lesions. 




Fig. -56. — Histology of Duhring's disease. Section of one of the bullae represented 
in Fig. 55. Note that the bulla is subepidermic; the epidermis has been raised as a 
whole by the fluid exudate. Among the white corpuscles seen at the floor of the 
cavity or scattered in the cutis are many eosinophile cells. X 50. 

Etiology and Character. — Although a rare affection, Duhring's 
disease is nevertheless the most common bullous disease of the 
pemphigus group. It seems to be more widely distributed in England 
and in America. It is observed in very young children, in youthful, 
middle-aged or old individuals, in both sexes alike. [In American 
dermatological practice it is seen in the ratio of one case out of five 
hundred.] 

The etiology is unknown and the cause has been sought in a neuro- 
pathic constitution, overwork, emotional disturbances, alimentary 
or medicinal intoxications. The disease is not at all contagious 
nor can it be inoculated. Two principal theories are held by the 
majority of writers: Some believe that endogenous or exogenous 



1S4 BULLM AND BULLOUS DERMATOSES 

toxins of microbic or other origin act upon the nervous system, 
causing the pruritus and the eruption. In the opinion of others the 
eosinophils, which in this disease exists in the blood as well as in 
the cutaneous lesions (as shown by the investigations of Leredde 
and Ch.Perrin), indicates its hematogenous origin (hematoderma), 
the bone-marrow being probably primarily affected. 

Eosinophilia, the significance of which is, moreover, imperfectly 
understood, may, however, be absent in Duhring's disease, whereas, 
on the contrary, it sometimes [commonly] exists in other bullous 
affections, pemphigus foliaceus, pemphigus vegetans and even 
exceptionally in chronic pemphigus, as I have been able to demon- 
strate. 

Treatment. — All lotions and applications in common use for itching 
affections June been tried, with variable results. Some cases may 
derive benefit from the employment of absorbent powders, or moist 
dressings, which, however, tend to mac-crate the epidermis; or 
from the application of Hme-and-oil liniment or various creams; 
while others do well under simple pastes, or even sulphur or tar 
pastes. Large bulla? should be pierced with a flamed needle; the 
excoriations are dressed with naphtalan, cold cream or lanolin. In 
ease of very extensive lesions where the dressing exhausts the patient 
too much, he may be placed between two sheets in a thick layer of 
talcum powder (dry treatment). 

(lateral Treatment- 'Die most popular internal treatment is 
arsenic, in progressive long-continued doses, administered in hypo- 
dermic injections, if necessary. Novarsenobenzol has been found to 
be very efficacious in certain cases. Balzer advocates adrenalin. 
I have sometimes obtained remarkable but very unreliable results 
from repeated injections of physiological salt solution or isotonic 
sea-water, or sugar solutions, hypertonic or not. It must be kept in 
mind that hypodermic injections in large doses, and still more so 
intravenous injections, with or without preliminary bloodletting, 
may give rise to a well-marked febrile reaction. It is desirable to 
further investigate this mode of medication, as well as serotherapy 
with organic sera in its different forms (autoserotherapy, etc.). [On 
the subject of autoserotherapy the views of American authors are 
greatly divergent; a few speak enthusiastically of its value, others 
find it of no use.] 

In all cases a very strict diet must be prescribed, free from 
stimulants, preferably a milk diet, and all organic functions must be 
carefully supervised. 

Rare Dermatoses Related to Duhring's Disease. — Under this 
heading I have grouped a number of pathological forms which have 
received special names, but are perhaps merely varieties of the dis- 
ease described above. This remark is certainly true of herpes 



RECURRENT PEMPHIGUS OR DUH RING'S DISEASE 185 

gestationis of Milton and Duncan Bulkier. This condition is really 
a Duhring's disease, with the special characteristic of developing in 
the course of pregnancy, in the fifth to sixth month, or sometimes 
after delivery. The attack lasts a few weeks to several months. 
Recurrence is the rule with each succeeding pregnancy, each attack 
occurring earlier in the course of the gestation and lasting longer. 

Hydroa puerporum of Unna is in all probability likewise a form 
of Duhring's disease, appearing in young children in the form of 
acute polymorphous attacks, recurring especially in the summer 
and disappearing around the age of puberty. 

Hydroa Vacciniforme of Bazin, or Summer eruption of Hutchinson, 
seems to be an altogether different kind of affection. The eruption, 
sometimes preceded by general malaise, accompanied by a burning- 
sensation and local tension, is not polymorphous, but vesiculo- 
bullous. At first tense and prominent, the small lenticular bulla? 
spread out, become umbilicated, attain the size of a finger-nail, 
become transformed into brownish pustules with a central depres- 
sion and dry in crusts which leave cicatrices resembling the pits of 
smallpox. Central necrosis is occasionally noted. 

The eruption occupies the exposed regions, especially the cheeks, 
the nose, the ears and the hands, being very rarely found elsewhere. 
It appears in the spring, under the influence of exposure to light, 
notably short-wave rays, as has been demonstrated experimentally. 
The patients, as a rule, have hematoporphyrinuria. The affection 
begins in the first few years of life, and usually ceases spontaneously 
at the age of twenty to thirty years. 

There is accordingly a hypersusceptibility to light radiations, due 
to abnormal tissue-juices; it is an established fact that hemato- 
porphyrin sensitizes toward the action of light. 

As to the relations of Impetigo herpetiformis of Hebra-Kaposi, 
studied in France by Dubreuilh, with herpes gestationis and Duhr- 
ing's disease great uncertainty prevails. This very rare affection is 
practically restricted to pregnant women, although a few cases are 
said to have been observed in men. 

The eruption consists of red and swollen nummular spots which 
became covered with small miliary pustules, increase in size and 
became confluent in large surfaces, crusted in the center and pus- 
tular at the periphery. It usually starts in the inguino-crural region, 
the umbilicus, the loins or axilla?, and may become generalized, even 
involving the mucosa?. Severe general symptoms are present, in 
the form of chills, remittent fever, a typhoid condition, tetany, 
eclampsia. In 19 of 84 cases collected by Borzecki, the outcome 
was death. 

No cultures can be grown on ordinary media from the contents of 
the pustules. If the condition is not a septicemia, but another 



186 BULLJE AND BULLOUS DERMATOSES 

pregnancy auto-intoxication, as in herpes gestationis, it would be 
reasonable to try injections of serum from normal pregnant women. 

It is also not known at the present writing if the continuous acro- 
dermatitis of Hallopeau and others, or recurrent phlyctenoses of the 
extremities of Andry, are pyodermatitides favored by a predisposed 
trophoneurotic territory, or clinical forms of 1 hihring's disease. The 
affection begins, at any age, under the guise of a whitlow; but new 
purulent bullne form incessantly, invading the entire finger, then 
other fingers and the hand, in islands or over a continuous surface. 
The other extremities are attacked in their turn. Radiating pains 
and pruritus are present. The affection lasts for years, with 
paroxysms, but without healing nor extending over the body. The 
nails finally fall out (compare impetiginous onyxis); the skin 
becomes atrophic and remains red. 

Aside from this suppurative form of acrodermatitis, a vesicular 
form has been described, characterized by isolated vesicles, on a red 
base, incessantly reproduced on the same fingers and related to the 
zosteriform eruptions. 



CHRONIC PEMPHIGUS. 

This name, or that of genuine pemphigus (pemphigus vulgaris), 
is reserved by me, with Besnier and Brocq, for a rare and almost 
invariably fatal progressive bullous disease, the most dangerous 
among the great malignant skin diseases. 

Symptoms. — Genuine pemphigus usually begins about the mouth, 
the pharynx or lips, the nasal fossae [the conjunctivae], or some- 
times on the anterior aspect of the chest. 

The eruptive lesion on the skin consists of round rather large- 
sized bullae, of nummular dimensions, tense or flaccid, with yellowish 
or turbid contents. They develop very rapidly on the healthy skin ; 
their base becomes reddened at the end of a few hours, or when they 
suppurate. Whether ruptured or not, they may undergo two different 
evolutions, either drying in crusts which are shed at the end of eight 
or ten days and leave a red or brownish macule; or the roof of the 
bulla becomes detached, exposing a, smooth bright red surface which 
sometimes suppurates. They do not enlarge much, but multiply in 
incessant new crops. 

In advanced stages of the disease the erosions are slow to become 
covered with epidermis; they run together here and there in poly- 
cyclic, raw or crusted lesions, surrounded by bullous elevations 
(Fig. 57) and may cover a considerable portion of the integument, 
more or less simulating eczema or an exfoliative dermatitis. 

According to the contents and the behavior of the bullae, the 



CHRONIC PEMPHIGUS 



187 



terms hemorrhagic, ulcerative, diphtheroid, gangrenous pemphigus, 
etc., have been employed. 

The eruption occupies especially the folds, the neck, the axillae, 
the anogenital and inguinocrural regions, the umbilicus, the periph- 
ery of the nails, as well as points subjected to pressure, such as the 
buttocks, trochanters, scapulae, knees, heels, ears; but there is a 
tendency to almost complete generalization. 




Fig. 57. — Genuine chronic pemphigus in an exhausted old man. The eruption dates 
a month back, the patient died less than seven weeks from the time of its onset. 



In the mouth the lesions are primary or precocious, very transi- 
torily bullous, assuming the appearance of a diphtheroid angina or 
ulcerative membranous stomatitis, and promptly spreading to the 
lips. The nasal, conjunctival, vulvar and other mucous membranes 
are very often affected in a similar way. 



188 BULLAE AND BULLOUS DERMATOSES 

At ;i certain stage of the disease Nikolsky's sign is invariably 
present; by forcible pressure exerted on the patient's skin with the 
pulp of the finger, the horny layers can be detached and made to 
slip off; moreover, a moderate amount of pressure gives rise to the 
appearance of a bulla. This sign, which indicates acantholysis, is 
also met with in pemphigus foliaceus, in congenital pemphigus, and 
in the grave form of Duhring's disease. 

Pruritus, formication and heat sensations may he entirely 
absent, the bullae developing without the patient's knowledge when 
this is the case, in contradistinction to Duhring's disease. But the 
excoriations, sores and buccal lesions cause severe pain. Adhesions 
may develop between two mucous surfaces; serious changes of the 
conjunctivae and cornea- may occur; the nails and hairs fall out. 



- 

Fig. 58. — Histology of genuine chronic pemphigus. Flaccid subcorneal bulla, very 
recently developed, derived from the case shown in I"i<r. 57. The cavity contains 
a sero-albuminous fluid in which float numerous white corpuscles arid a few 
epithelial cells. The adhesion of the epidermal cells with each other is diminished: 
on the borders of the blebs, the corneal layer tends to become detached from the rete; 
Nikolsky's sign was present to a marked degree in this case. X 65. 

The general phenomena consist of nervous depression or excite- 
ment, anorexia, extremely rapid emaciation ; finally diarrhea, 
vomiting, cachexia and sometimes a transformation into pemphigus 
foliaceus, lead to death. Fever has been noted, being sometimes 
accounted for by the existence of abscesses, ulcers, or sloughs. 

The course is rapidly progressive. The fatal termination takes 
place in three to eighteen months, rather less than more, through 
cachexia or an intercurrent infection. 

Cases have been reported, and have come under my personal 
observation, possessing all the characteristics of true pemphigus, 
instead of Duhring's disease, which nevertheless terminated in 
recovery or in a complete remission lasting several years. We are 
obliged therefore to admit the existence of a benign form. 

Diagnosis. This is usually very precarious at the onset, and it 
has well been said that there exist no two exactly similar cases of 



PEMPHIGUS FOLIACEUS 189 

genuine pemphigus. The most experienced dermatologists some- 
times hesitate in the presence of the early lesions which have the 
appearance of stomatitis, angina, toxidermia, hydroa, or Duhring's 
disease. In the developed stage, the clinical picture becomes clear 
and more or less approximates the description given above. 

Pathological Anatomy. — The bulla? are so fragile that it is difficult 
to obtain unruptured specimens for examination. The cavity may 
be subcorneal, intramalpighian, or subepidermic. Underneath the 
bulla, the derma is edematous, but contains only a few wandering 
cells. 

The subjoined figure (Fig. 58) gives an idea of these lesions. 

Eosinophils are not usually found either in the fluid contents of 
the bullse or in the neighboring tissues. The contents are sterile or 
enclose microbes of secondary infections. Blood cultures are usually 
negative. The investigations of Lipschutz point to protozoa as 
the responsible agents. [?] 

Etiology and Character. — Chronic pemphigus attacks especially 
weakened exhausted individuals past the age of forty years, some- 
what more frequently males. The Jewish race seems to be pre- 
disposed to it. 

The disease is not contagious, and there is nothing to prove its 
infectious character. It may equally well be claimed to result from 
a severe affection of the central nervous system, or possibly from 
an auto-intoxication. 

Treatment. — The external treatment is that of the other bullous 
skin affections. Internal medication has for a long time been con- 
sidered absolutely ineffective, so that the patient's strength was 
simply kept up by means of nourishing food, fresh air, tonic medic- 
inal agents, strychnin, etc. Recently, various authors have re- 
ported improvement and even cures, by means of quinin (1.0 to 2.5 
gm. daily), antipyrin, arsenic, and especially arsenobenzol, as well 
as by injections of normal serum. These therapeutic measures 
should accordingly be resorted to, instead of considering the situ- 
ation as hopeless. 

PEMPHIGUS FOLIACEUS. 

This term is applied, since Cazenave, to a skin disease which 
begins with pemphigus and becomes transformed into an exfoliative 
erythroderma. It is difficult to give a clear description of its 
extremely variable clinical picture and course. The onset may be 
that of chronic pemphigus, or more rarely Duhring's disease; or 
there may be a bullous dermatosis impossible of classification, 
with rare and discrete, then numerous and close-set bulla?, often 
remarkably flaccid. Depending on its course, pemphigus foliaceus- 
is called secondary or primary, 



100 



BULL.E AND BULLOUS DERMATOSES 



In the transition-stage, no more normal epidermis is formed at 
the points occupied by the bullae, but instead lamellar, leaf-like, 
moist scales or crusts, which cover large red surfaces, sometimes 
extending over almost the entire body (Fig. 59). This epidermis 
is incapable of forming the roof of blisters and these are replaced by 
oozing spits from which the scales arc easily detached. Under the 
scales or at the macerated points, a highly offensive epidermic mass 




foliaceus of four ye 
twenty-five years. 



:i woman 



a god 



is found, made up of isolated Malpighiaii cells. On the borders of 
the squamous surfaces is seen a bullous margin, especially in the 
vicinity of the hands and feet which sometimes escape. 

Finally, the lamellar exfoliation becomes general and resembles 
that of the other erythroderniias; it is sometimes so abundant that 
handfuls of epidermal structures can be picked up from the patient's 
bed. However, it usually retains a peculiar moisture. 



CONGENITAL PEMPHIGUS 191 

The skin is a dark or brownish red, thinned and tense, or not 
infrequently papillomatous; fissures appear in the articular folds 
and ectropion develops on the eyelids. The hairs of the scalp and 
body become scanty; the nails become streaked and hooked and may 
fall out. The mucous membranes usually remain intact. 

Pemphigus foliaceus is the disease in which Nikolsky described 
the sign of easy detachability of the horny layer, which he believed 
to be pathognomonic. 

Pruritus and heat sensation are not prominent, except period- 
ically. The urine is scanty and the urea and nitrogen index is 
always low. 

The disease is protracted, sometimes lasting five to ten years, 
often only two or three years. It regularly terminates in death, 
due to digestive disturbances, especially diarrhea, marasmus, or 
intercurrent complications. 

The pathological anatomy has yielded divergent findings. The 
epidermis was found to be tense and thinned or there were greatly 
elongated papillse and intrapapillary buds, with dermic and epidermic 
edema and abundant exocytosis. The condition of the granular 
layer is variable. Eosinophilia is noted in the blood. Various 
lesions of the nerve centers have been described, but are inconstant. 

Pemphigus foliaceus is encountered in both sexes, among adults 
in a state of physical or psychic deterioration. 

We do not know if it is of nervous, toxemic, hematodermic, or 
other origin. It seems that certain cases can be interpreted as 
malignant exfoliative herpetides, secondary to a pemphigus; the 
appearance of other cases is that of a distinct pathological entity. 

The treatment must follow that of the other bullous skin diseases 
and the erythrodermas. 

CONGENITAL PEMPHIGUS. 

This is a cutaneous malformation rather than a disease ; it is very 
rare, usually familial or hereditary, as a rule congenital, but occasion- 
ally does not mainfest itself until late childhood, or still later. From 
various sources attention has been called to the apparent influence 
of consanguinity of the parents. 

It consists of a predisposition of the skin and sometimes of the 
mucous membranes, to react in the form of bullse toward all trau- 
matisms, pressures, or even slight bruises. 

Two degrees are known, and by some are considered as separate 
types of the disease: The first, epidermolysis hereditaria bullosa 
of Kobner, or simple traumatic hereditary pemphigus, consists 
merely of a tendency to the formation of tense, subcorneal, serous 
or sero-sangumolent blisters; these develop in the healthy skin, 



192 HI 1.1..K AND BULLOUS DERMATOSES 

under the influence of blows, or pressure by the clothing, shoes, 
etc. The feet, hands, wrists, elbows, knees, etc., and even the 
buccal mucosa arc affected with blebs, which come on without pain 
in less than an hour after the traumatism and which heal very 
readily, provided infection does not occur. 

In the second, the grave and dystrophic form — "Pemphigus 
successif a Kystes epidermiqujes" or congenital pemphigus with a 
tendency to cicatrization — an apparently spontaneous production 
of more or less numerous bullae is noted at various points of the 
limbs and body, within a short time after birth. There is a constant 
succession of these bullae, especially in regions exposed to pressure, 
on the extremities, the ears, the knees and elbows, even on the 
mucous membranes. 

Gradually the skin of certain regions, principally that on the 
back of the hands and the joints of the fingers, the elbows and knees, 
etc., becomes atrophic or cicatricial, thin like onion peel, of a 
brownish purplish-red color. An enormous number of very small 
white opaque granules are seen; these are milium cysts. The nails 
undergo various deformities, or fall out permanently. 

The microscope discloses atrophy of the derma with disappear- 
ance of the papillary body and shows that the cysts are dilatations 
of the sweat ducts with corneal contents or more rarely follicular 
cysts. Similar miliary cysts and atrophic changes are noted in some 
cases of 1 hihring's diseases. 

In the congenital forms of pemphigus, Xikolsky's sign of easy 
detachability of the horny layer is almost invariable present. In 
certain cases, a combination has been demonstrated between 
congenital pemphigus and various forms of congenital ichthyosiform 
hyperkeratosis. On the other hand, Nicolas, Montot and Charlet 
have described a type with chronic and progressive vegetative 
ulcerations. 

'Phe pathological predisposition usually diminishes with the 
advance of years; or it may become limited to some particular 
region. 

The patient must be cautioned against all exposure to traumatism. 
Protective dressings and tonic internal medication are indicated. 

PEMPHIGUS HYSTERICUS. 

Hysterical pemphigus does not exist, as has been shown by 
investigations and conclusive discussions. 

1 fnder tins name, or under that of drginal or chlorotic pemphigus, 
were designated attacks of bullous eruptions, hemorrhagic, pustular 
or sloughing, which occurred in nervous girls or young women of 
peculiar character. 



PEMPHIGUS HYSTERICUS 193 

The lesions, often of an irregular or elongated shape, are^dis- 
tributed in a remarkable fashion, sometimes with suspicious regular- 
ity. They appear one by one, or in small numbers at a time, 
throughout a period of several months or years. The course is 
invariably benign. However, through their extent, numbers and 
sometimes gangrenous character, the lesions may cause actual 
mutilations. 

In all cases which could be seriously investigated, where the 
patient was carefully watched, or when, for example, a sealed 
occlusive dressing was applied over the affected region, the condition 
could always be traced to malingering. The lesions are burns or 
cauterizations by chemical or medicinal agents and are produced by 
the patient herself under the influence of a special mental state which 
has been named mythomania or pathomania. These are cases of 
dermatitis artefacta. The truth of Babinski's statement is beyond 
question, that hysteria is incapable of giving rise to trophic dis- 
turbances of the skin. 

The exposure of trickery demands some tact on the part of the 
physician, whose suspicions are often repudiated by the patient's 
environment. But when the proof of the fraud has once been made, 
the so-called eruption subsides of its own accord. 



13 



CHAPTER XI. 
KERATOSES. 

HYPERKERATOSES AND DYSKERATOSES. 

The name keratosis is applied to a dermatological lesion which 
consists in moderate thickening of the horny layer; hyperkeratosis 
means a considerable hyperplasia of this layer; dyskeratosis is a 
pathological process in which a disturbed keratinization terminates 
in the formation of an abnormally constituted corneal layer, with 
thickening in some of the cases and disintegration in others. 

Under normal conditions, the horny layer is formed by the super- 
posed layers of lamellar cells, which are composed of keratin and 
loaded with fat, but have neither protoplasm nor nuclei. These 
corneal cells represent the ultimate stage of the process of epidermic 
development. Originating through multiplication of the constit- 
uents of the basal layer, the Malpighian cells are gradually pushed 
up by the newly generated cells and reach the granular layer where 
they take up eleidin or keratohyalin, after which they suddenly 
undergo the transformation known as keratinization. 

The corneal cells adhere to each other and persist a certain time 
at the epidermal surface, where they constitute a resistant, supple, 
and only slightly permeable protective covering. Being no longer 
alive, the horny cells are incapable of vital reaction against irritants 
of any kind and are finally shed. 

The thickness of the normal horny layer varies slightly in diffei- 
ent individuals and greatly in different regions of the body. 

I shall begin with a discussion of the cutaneous affections char- 
acterized by thickening of the horny layer, leaving to the end of 
the chapter the conditions designated dyskeratoses. 

KERATOSES AND HYPERKERATOSES. 

In the cutaneous affections characterized by a thickening of the 
horny layer the degree' of this hyperplasia is variable — being 
slightly marked and accompanied by a, powdery or scurvy desqua- 
mation in kerosis and pityriasis simplex or considerable, often 
producing a. genuine carapace, resistant and liable to crack, in the 
iclitliyosiforni hyperkeratoses and numerous keratodermias; in 
ichthyosis, all degrees arc met with, from simple xerodermia to the 
most pronounced sauriasis. 



KERATOSES AND HYPERKERATOSES 195 

In a general way, when the horny layer is very hyperplastic, the 
granular layer and the mucous body are, as a rule, likewise of very 
abnormal thickness; the derma itself is usually congested and 
there is an obvious tendency toward the production of papillary 
elevations or vegetations. 

The name of verrucosa state is applied to the common combination 
of keratosis with the vegetative process (XII). 

The term keratoma is sometimes applied to a circumscribed 
hypertrophy, forming a tumor, such as cutaneous horns. 

From the point of view of the distribution of the lesions on the 
surface of the integument, a distinction must be made between 
the following groups : 

1. Diffuse and generalized keratoses, spreading over almost the 
entire body, or at least over large surfaces, although with evident 
regional predilections. 

In this group I shall describe kerosis, pityriasis simplex, ichthyosis 
and the generalized and partial ichthyosiform hyperkeratoses. 

2. Circumscribed keratoses, composed of distinctly limited kera- 
totic spots or surfaces; some are scattered without apparent order, 
others assume a regional or symmetrical arrangement, while a few 
are even distinctly systematized. 

This group comprises: keratotic neii, linear nevi, senile warts, 
senile keratosis and a few analogous affections. 

It is not superfluous to point out that keratotic lesions in scat- 
tered spots or on more or less extensive surfaces, may be present or 
simulated, in a large number of skin affections. But corns, flat 
warts and common warts have been described elsewhere. The 
cutaneous dystrophies such as acanthosis nigricans, which is vege- 
tative and xeroderma pigmentosum, in which the lesions of the 
derma are important and essential, likewise belong in other chapters. 

As regards the patches of psoriasis inveterata and ostreacea, 
lichen hypertrophicus, lupus erythematodes of the type of "herpes 
cretace," tuberculosis verrucosa, the angiokeratomas, etc. — the 
thickening of the horny layer here is secondary to a definite process 
of different character. They are here mentioned only from the 
viewpoint of the differential diagnosis. 

3. Regional keratoses proper, which owe very peculiar character- 
istics to their topographical localization. Such are notably the 
palmar and plantar keratoses, for which I reserve the name of 
keratoderma. 

Although the epithelium of the mucous membranes, more par- 
ticularly that of the mouth, does not, under normal conditions, 
become keratinized like the epidermis, local pathological lesions are 
observed which are properly entitled to the name of keratoses of the 
mucosce. 



196 KERATOSES 



KEROSIS. 



The chronic pathological condition of the skin which I have 
named kerosis, is characterized clinically by: (1) Dirty yellowish 
or grayish coloration; (2) accentuation of the pilo-sebaceous pores; 
(3) a slight thickening of the integument. 

The anatomical lesions are: A slight diffuse hypertrophy of the 
horny layer, with a tendency to fine desquamation and a modifi- 
cation, of unknown character, of its fat content; hyperkeratosis 
of the pilo-sebaceons orifices. 

This dystrophy finds its proper place in the group of. the diffuse 
keratoses. It is usually misinterpreted and confused, erroneously 
in my opinion, with seborrhea, which constitutes merely a complica- 
tion. 

Although of slight importance in itself, kerosis acquires clinical 
interest because it furnishes the necessary or ordinary substratum 
for several of the most common cutaneous affections. Such are 
certain pityriases, seborrhea, certain alopecias and hypertrichoses, 
hyperidrosis oleosa, some acnes, rosacea, many cczonatides. 

The kerotic pityriasis will be described in the following paragraph. 
For the other kerotic affections, the reader is referred to the chapters 
dealing with the follicnloses, trichoses, hidroses and the erythemato- 
squamous dermatoses. 

The topographical distribution of kerosis is both diffuse and 
regional. It occupies by predilection and to the highest degree, the 
center of the face, especially the nose and the nasogenial furrows, 
and the seal]); very frequently also the forehead, the temples, the 
chin, the nape of the neck; on the trunk, it affects especially the 
pre-sternal oval and the interscapular groove, spreading more or less 
around the middle line. It often covers the shoulders, the entire 
thorax, uniting at the sacrum behind, at the umbilicus in front; it 
is not uncommon on the pubis, the genital organs, the intergluteal 
fold, in the large articular folds and even on the palms of the hands. 

The following parts invariably escape: the front of the neck, the 
extensor surface of the limbs, the buttocks and the forearms and 
legs as a whole. 

It will be noted that, this distribution is practically the opposite 
of what is seen in ichthyosis. 

On this territory, the various manifestations and complications 
of kerosis are not produced haphazard, but each has its preferred 
or exclusive regions. 

Numerous factors play a role in the etiology of kerosis. This 
anomaly is so widely distributed in civilized countries and in its 
mild degrees so close to the physiological condition, that one hesi- 
tates to define it as a disease. Certain individuals, more or less 



KEROSIS 197 

numerous according to the race, are immune. Direct heredity, 
or the influence of poor health or bad hygiene of the parents, 
constitute the fundamental conditions of kerosis. The establish- 
ment of the genital functions and sexual disturbances on the one 
hand, unhygienic diet on the other, in the form of a hypernitrog- 
enous diet, abuse of stimulants, coarse food, insufficient mastication, 
abnormal fermentations, constipation, etc., are common factors, 
the individual effect of which is not easily determined. 

External local irritation, reflex circulatory disturbances con- 
nected with affections of the mucous membranes, play a much less 
prominent part. 

By a certain school, the manifestations of kerosis are interpreted 
as directly microbic, each one, according to Sabouraud, being refer- 
able to a special variety of microbe or an association of varieties. 
The presence of microorganisms is indeed undeniable, but their 
pathogenic action has not been demonstrated. 

At any rate, kerosis and its manifestations follow a certain law of 
evolution in connection with the age of the individual. Dry pity- 
riasis of the hairy scalp, appearing at the age of six to ten years, 
becomes transformed about or after puberty into oily pityriasis, 
seborrhea developing at the same time. Acne juvenilis flourishes 
from the age of fifteen to twenty-five years. Calvities gravis 
begins at twenty-five years, or less. . Rosacea may be premature, or 
be delayed until about the age of forty-five years. In aged indi- 
viduals, the sequelae of kerosis become attenuated and extinct, unless 
it be held accountable for seborrheal warts and senile keratosis. 

It is quite possible that the vernix caseosa, or the greasy epidermic 
covering of some infants at birth and the so-called acne miliaris of 
the newborn which may accompany it, represent the first mani- 
festation of kerosis. This would be an additional reason for regard- 
ing the latter, accepting the views of Jacquet, as closely related to 
sexual development. As a matter of fact, kerosis has two periods 
of florescence, that of the genital wave at the time of birth, and 
that of puberty; and a period of decline, when sexual life is 
restricted. 

The treatment of kerosis must consist in the first place in cor- 
recting all hygienic deficiencies which may be present. It may 
be necessary to administer alteratives, such as phosphates, cod- 
liver oil and especially arsenic on account of its keratoplasty 
properties. 

Mineral springs, with sulphur, arsenic or sodium chloride water, 
are especially indicated. 

Locally, sulphur in the form of sulphurous or sulphur lotions, soaps, 
glycerolates, pastes or salves, but also the tars, camphor, calomel, 
reducing agents in general, are very serviceable. 



198 KERATOSES 

With perseverance, it will almost invariably prove possible to 
obliterate the principal kerotic manifestations and to restore the 
skin, if not to normal, at least to a condition very close to normal; 
relapses, however, are common. 



PITYRIASIS SIMPLEX. 

The name of pityriasis simplex is applied to a non-inflammatory, 
scurfy, bran-like desquamation of the horny layer. 

The term pityriasis, derived from the Greek irlrvpov meaning 
"bran," is on the other hand applied to various pathological con- 
ditions which have nothing in common with the subject under 
discussion. 

Pityriasis versicolor is a specific parasitical disease of the epidermis; 
pityriasis rosea of Gibert is an erythemato-squamous dermatosis; 
pityriasis rubra pilaris belongs rather with the folliculoses; pityriasis 
rubra is an erythroderma. 

Pityriasis simplex must be distinguished from the pityriasiform 
desquamations following upon an inflammation, such as may be 
observed after the erythemas, eruptive fevers, pyodermatitides, 
or in the course of certain trichophytoses and especially of eczemas. 
In these cases, the desquamation almost invariably results from 
the phenomenon known as parakeratosis. 

In pityriasis simplex, on the contrary, the keratinization of the 
epidermis is complete, and takes place, at least apparently, in a 
normal manner; but the corneal epithelium is thickened and peels 
off in scurfy lamellae or scales, instead of in a fine powdery and 
imperceptible form as on the healthy skin. 

In accordance with this definition, pityriasis simplex is one of tin- 
most common manifestations or consequences of kerosis. Hence 
there is nothing to add in regard to its etiology, to what has been 
stated concerning this dystrophy; but I wish to emphasize again 
the influence of age upon its course. 

Those authors who include the entire picture of keratosis under 
the incorrect name of "seborrhea," have been led, after Ilebra, to 
consider pityriasis simplex as a "seborrhea sicca;" but this expres- 
sion is in every way inadmissible. 

Pityriasis simplex is almost exclusively met with, or at any rate 
decidedly predominates in the hairy regions and especially on the 
seal]), where it is designated as pityriasis capitis. Next in order, it 
affects the beard, the pubis, the hairy regions of the thorax and 
sometimes the limbs. 

Two varieties can be distinguished, which are connected, how- 
ever, by a series of intermediary forms. 



PITYRIASIS SIMPLEX 199 

Pityriasis sicca is a condition in which there is an incessant 
reproduction of dry white or grayish lamellae, called dandruff by 
the laity. An extreme degree was formerly described as "teigne 
amiantacee (asbestos-like tinea), a name suggested by Alibert. Its 
mild degrees blend with the physiological desquamation which is 
encountered on any neglected scalp or improperly kept beard and 
even on the entire body of bedridden patients. 

In pityriasis oleosa, which often follows upon the preceding, the 
scales are oily, greasy, yellowish, sticky; but it is noteworthy that 
they occur on a skin of normal coloration, without pathological 
redness. 

The oily character of this pityriasis might appear to be referable 
to its association with seborrhea (supra-seborrheal pityriasis of 
Sabouraud). This combination is frequent, but not constant. 
There is an oily pityriasis without seborrhea in the same location ; 
the fat is derived from the keratinization itself. 

As regards the steatoid pityriasis of Sabouraud, this is not a 
simple pityriasis, but an eczematide on a kerotic soil. It furnishes 
no scales, but crusts, the consistence of which is due to dried serum; 
the skin where they occur is pink and moist and pruritus is often 
present. The so-called milk-crusts of children usually belong to this 
variety. 

Although we are not justified, in my opinion, in regarding pity- 
riasis simplex as of parasitical origin, it is necessary to point out 
the remarkable abundance of microorganisms in its scales. The 
predominating parasite is the spore of Malassez, or bottle bacillus; 
it is very polymorphous, rather large, assumes the forms of 
yeasts, but has so far resisted all attempts at artificial culture. It 
is associated with the bacillus of seborrhea in oily pityriasis, and 
with various cocci, chiefly the polymorphous coccus of the skin 
(coccus cutis communis) in the so-called steatoid pityriasis. 

Pityriasis simplex is merely an unpleasant, hardly a troublesome 
affection, in itself; it is feared only on account of the alopecia and 
baldness which are attributed to it. Aside from this, it exposes 
to the danger of eczematides and must therefore be systematically 
controlled. 

The treatment of pityriasis capitis requires in the first place local 
measures; frequent washing with sulphur, naphthol or tar-soaps, 
or better with a decoction of quillaya bark [saponin], aqueous 
solutions with sulphur, coal tar, etc., or alcoholic and ethereal, 
mercurial, naphtholated or compound lotions, several formulae for 
which may be found at the end of this book. Ointments are not 
agreeable to the patient, but it is advisable to employ them in 
severe cases, at least for nocturnal treatment. 

The general hygiene and that of the hair and its arrangement 



200 KERATOSES 

must be properly regulated. Analogous measures are applicable 
in pityriasis of the beard or other regions. 

Pityriasis Simplex of the Face and Hairless Parts is limited to 
children and youthful individuals with delicate skins. It is found 
around the mouth, on the cheeks, the chin, the front of the neck, 
and sometimes on the trunk and the limbs. It appears in the form 
of rounded, oval spots or more or less distinctly outlined polycyclic, 
scurfy or furfuraceous areas, with a normally colored or slightly 
pinkish surface, ligher than the background when the complexion 
is tanned or sun-burnt. 

This superficial dermatosis is contagious and even epidemic in 
groups of children. It may coincide with impetigo and Sabouraud 
regards it as a dry impetiginous epidermatitis, due to staphylococci. 
It may become eczematized and should probably be classified with 
the mild eczematides. 

It is very readily curable by means of mild sulphur or white 
precipitate ointments, etc. 

ICHTHYOSIS. 

Ichthyosis is a diffuse generalized keratosis which is never con- 
genital but which manifests itself at an early age and persists 
throughout life. It is usually considered a malformation of the 
skin. 

Symptoms. — The ichthyotic skin is dry and scaly. In typical 
cases of moderate severity, the integument is roughened, parch- 
ment-like, covered with dry scales which have been compared 
with fish scales; they are thin, white or brownish or gray, more or 
less easily detached and constantly renewed. 

Many degrees or objective varieties of ichthyosis can be described : 
In xeroderma the skin is merely dry and the desquamation is 
powdery, almost imperceptible; "ichthyosis nitida, or nacreous 
ichthyosis, with thin and silvery lamelhe, is the most common form; 
in ichthyosis nigricans or black ichthyosis, the scales are of a dark 
color; they are large and polygonal in ichthyosis serpentina; large, 
thick and resembling the skin of the crocodile, in sauriasis; finally, in 
ichthyosis hystrix, prominent warty or pointed horny excrescences 
are seen, suggestive of the porcupine's skin. 

The two last named varieties are sometimes combined under the 
name of ichthyosis cornea; it is very probable that they do not 
legitimately belong to ichthyosis but to the ichthyosiform hyper- 
keratoses, which will be discussed further on. 

Ichthyosis is always symmetrical and is most marked on the 
extensor surface of the limbs, especially the elbows and knees i Fig. 
GO), but also the trunk and to a less degree, the head and hands and 



ICHTHYOSIS 



201 



feet. The face is, as a rule, only slightly xerodermic; the scalp is 
pityriasic; the palms of the hands and the soles of the feet are very 
often dry and wrinkled like the hands of washerwomen. 

On the other hand, the articular folds, axillae, elbow bends, 
popliteal spaces, intergluteal fold, groins and the genital organs 
are always more or less free, in contradistinction to what is seen in 
the ichthyosiform hyperkeratoses. Lesions of mucous membranes 
are altogether absent. 

On passing the finger-nail or some pointed object over the skin of 
ichthyotic patients, a white powdery track is left behind; the skin 
often appears tense and when it is grasped between two fingers the 
papillary body folds up superficially over the derma. The hairy 
system may be normal or is imperfectly developed; the downy 
hairs of the extensor surfaces are very fine, resembling lanugo and 
sometimes appear to be thinned; the co-existence of keratosis 
pilaris is invariable. 




Fig. 



-Ichthyos 



nitida in a youth aged sixteen years. Note the white mark left 
by the garters above the knees. 



The nails are normal, or rarely dry and brittle. The sebaceous 
and sweat secretions are greatly diminished; heat or violent exer- 
cise may cause sweating in mild cases of ichthyosis and the affec- 
tion will then become attenuated or disappear, as for instance, in 
the summer. Ichthyotic patients are usually thin, poorly devel- 
oped and of slight resistance. 

Pruritus is not a feature in the clinical picture of ichthyosis, 
unless it is complicated by eczema, which is rather common. This 
eczematization is observed especially in persons neglectful of 
cleanliness and those exposed to artificial dermatitis, or even, it 
has been claimed, without an apparent local cause; the attacks 
may be obstinate and recurrent but always represent merely a- 
superadded complication. 



202 KERATOSES 

Ichthyosis is never strictly congenital; it develops gradually and 
is usually not observed until the third year of life, though some- 
times as early as the third or fourth month; often the date of onset 
cannot be accurately determined. It may become attenuated at 
the time of puberty, but as a rule it persists until death. Hebra 
and Hardy assert that it may disappear after eruptive fevers, but 
this is extremely doubtful. 

The name of ichthyosis tabescentium, desquamation of cachectics, 
and senile ichthyosis has been applied to a state of diffuse atrophy, 
with dryness of the skin and ichthyosiform desquamation, which 
develops in weak old people and bedridden invalids. 

It is not known if the pathological condition in these cases is 
always identical and how it is related to ordinary ichthyosis. 

Pathological Anatomy. — The horny layer is always more or less 
thickened; the granular layer is diminished or absent in the variety 
nitida, but there is no complete parakeratosis; the mucous body 
is rather thin and tense. The papillae are less developed than 
normal. The papillary body and the chorion are almost invariably 
found to contain a moderate infiltration of round cells and mast 
cells around the vessels; this fact has led Unna and Tommasoli to 
consider ichthyosis as an inflammatory skin disease. The pilo- 
sebaceous follicles present the lesions of keratosis pilaris. Various 
lesions of the sweat glands have been reported. 

The changes attributed to the hystrix form are identical with those 
of ichthyosiform hyperkeratosis and of the hyperkeratotic nevi; so 
that some doubt prevails as to the existence of a true ichthyosis 
hystrix. 

Etiology. — Ichthyosis, except in its mildest form, is not very 
common; its extreme degrees are actually rare. It is a hereditary 
malformation in one-fourth of the cases, familial in one-half of 
the cases, according to Gassmann; the transmission is irregular 
and may skip a generation. It is not certain and even rather 
improbable that alcoholism, syphilis or tuberculosis of the parents 
create a predisposition to the disease. Both sexes are equally 
affected. 

Diagnosis. — Mild xeroderma with or without keratosis pilaris, 
may be misinterpreted or confused on superficial examination 
with pityriasis simplex, kerosis, the post-eruptive desquamations, 
desquamations of cachectics, etc. When the onset of the affection 
can be determined, the point will be settled at once. 

In psoriasis, in the dry eczemas and in pityriasis pilaris, the skin is 
red. Psorospermosis, named ichthyosis follicularis by J. C. White, 
is quite characteristic. 

Ichthyosis must be differentiated especially from generalized 
ichthyosiform hyperkeratosis (congenital ichthyosis of certain 



ICHTHYOSIFORM HYPERKERATOSES 203 

authors), and from regional or very extensive systematized hyper- 
keratotic new,, many cases of which have been described under the 
names of ichthyosis partialis, ichthyosis hystrix, etc. 

Treatment. — Although the disease is incurable, the patients can 
be greatly relieved by maintaining their skin in a clean and supple 
condition. Arsenic seems to be of little use; cod-liver oil is to be 
recommended; thyroid medication may be cautiously tried. 

The external treatment, however, is of the greatest importance. 
Repeated and prolonged baths, washing with soap, steam baths, 
on the one hand and daily inunctions with vaseline, glycerin, fatty 
substances or various salves, on the other, will give the skin in a 
short time a nearly normal appearance in cases of moderately 
severe ichthyosis. The same measures must be insisted upon in the 
severe types. It is necessary to regulate the treatment in a given 
case in such a way as to keep up the results attained. 

ICHTHYOSIFORM HYPERKERATOSES. 

Under this heading must be grouped some interrelated dermatoses 
which differ from ichthyosis by the following characteristics: 

They may be strictly congenital or their appearance may be 
delayed for a shorter or longer time after birth; they usually take 
a progressive course; hyperkeratosis is more pronounced than is 
ichthyosis and is accompanied by a marked redness of the skin 
which has led to the name of ichthyosiform erythroderma; anidrosis is 
absent or may be actually replaced by hyperidrosis ; far from spar- 
ing the articular folds, the lesions on the contrary are especially 
well developed in these regions; their histological structure is alto- 
gether different. 

A distinction is made between a generalized form, to be described 
next, and circumscribed forms, which will be discussed in the 
succeeding paragraphs. 

Generalized Ichthyosiform Hyperkeratosis. — This is often named 
fetal, intra-uterine or congenital ichthyosis, for it is always present 
at the time of birth. Two degrees of the affection may be dis- 
tinguished. 

The severe type is incompatible with life; it has been referred to 
in the chapter on the erythrodermias. It represents a diffuse con- 
genital malignant keratoma. 

The benign type, distinctly separated from ichthyosis by Unna 
under the name of congenital hyperkeratosis, is characterized by a 
more or less severe and universal redness of the skin which is con- 
tracted and covered with large thick, polygonal, brownish scales 
resembling the scales of sauriasis, very adherent, but capable of 
being detached in a single piece by traction or maceration (Fig. 61). 



204 



KERATOSES 



The face is affected; it is pinkish and scaly; ectropion is usually 
present. The articular folds are the seat of horny, blackish, 
papillary excrescences. The palmar and plantar regions present 
the appearance of hereditary keratoderma. The hairy scalp is 
covered with a sebaceous coat. Brocq observed that in certain 



I [G. 61. < generalized 
Note the lizard-like aspect oi the 
popliteal spaces. 




■perkeratosis in a girl aged eight years, 
[tegument and the horny vegetations in the 



cases, which he calls ichthyosiform congenital erythroderma with 
hyper-epidermatro / phy, the hairs and nails grow two or three times 
as rapidly as in normal individuals. 

Especially in the first years, occasional crops of bullae may be 
observed on the limbs and on the trunk; I have shown that these 
bullae are auto-inoculable; they probably represent merely an 



ICHTH YOSIFORM H YPERKERA TOSES 



205 



impetigo, favored by the cracking of the epidermis (Fig. 62). All 
the symptoms, especially the redness, become attenuated with age. 
The majority of cases described under the names of ichthyosis 
cornea, sauriasis, ichthyosis hystrix, were in reality ichthyosiform 
hyperkeratosis. 




Fig. 62. — Generalized ichthyosiform hyperkeratosis in a boy aged thirteen years. 
External surface of right knee. The horny verrucous covering has been detached in 
places; at the level of the head of the fibula a bulla is seen, resulting from an experi- 
mental auto-inoculation. 



The pathological anatomy shows lesions altogether different from 
those of ichthyosis. The horny layer is enormously thickened and 
arranged like shingles on the acuminate protuberances; it contains 
considerably less fat than in the normal condition. The granular 
layer is markedly hypertrophied. The rete is thickened. The papillse 
are greatly elongated and irregular. Perivascular infiltration is not 
constant. 

Partial Ichthyosiform Hyperkeratoses. — Clinical observation 
and histology are in accord as to the relation with ichthyosiform 
hyperkeratosis, of familial keratoderma or Meleda disease, which 
seems to represent merely a regional and partial variety of this 
affection (p. 211). 

Notwithstanding its very remarkable course, it seems justifiable 
to connect with ichthyosiform hyperkeratosis also the rare disease 
symmetrical erythrokeratoderma, especially since it may become 
associated with familial keratoderma (Brocq and Dubreuilh). 



206 KERATOSES 

This uncommon skin affection, a typical case of which was re- 
ported by me in 1911, the face and upper part of the trunk alone 
escaping, appears after birth in the form of spots or isolated patches 
which spread rather rapidly and finally invade almost the entire 
internment; the keratotic surfaces may become warty and give rise 
to genuine cutaneous horns. 

All the hyperkeratoses of this group, generalized or circum- 
scribed, probably represent cutaneous malformations of the same 
kind as nevi; their sometimes delayed appearance, their symmetry 
and their extensive character, do not militate against this view. 
There are reasons for the belief that consanguinity of the parents 
and heredity play a certain part in their etiology. 

CIRCUMSCRIBED KERATOSES. 

Keratotic Nevi. — As with nevi in general, these may exist at birth, 
or develop in the course of childhood or even later. They appear 
in the form of spots, elevations or verrucosities which gradually 
become covered with a more or less thick coating of horny tissue. 

Hyperkeratotic and Varicose Nevi. — Hyperkeratotic and varicose 
nevi may be single or multiple, limited or very extensive, situated 
at any point of the integument. Some are regional and occasionally 
symmetrical, occupying for example certain articular folds. Others 
are covered with such a thick accumulation of horny substance as 
to constitute a genuine cutaneous horn, resembling a small ram's 
horn. 

Linear Nevi. — Linear nevi constitute a very peculiar systema- 
tized form of hyperkeratotic nevi. The verrucosities, of a gray, 
brown or black color, are arranged in continuous or interrupted 
streaks of great length and variable width, often in very regular 
patterns. Sometimes unilateral, in other cases symmetrical, these 
nevi are made up by a single streak or several streaks following a 
parallel course. I have repeatedly observed the entire body, includ- 
ing the limbs and the face, to be covered by linear designs of this 
kind (Fig. I'm). On the limbs the streaks are longitudinal, often 
partially spiral. On the trunk, they are horizontal or rather oblique 
and frequently present angular inflections, forward and backward, 
in the vicinity of the middle line, which itself maybe traced by a 
streak. In the face, the lines are orbicular or radiating in various 
directions. 

An explanation of these distributions which do not seem to be 
the result of accident, has taxed the ingenuity of observers. The 
direction of the streaks has been referred to that of the nerves; to the 
lines of Voigt, separating the nerve territories; to the lines of cleavage 
of the skin; to the course of the bloodvessels; to the metameric 



CIRCUMSCRIBED KERATOSES 



207 



zones of Head; to the lines of fusion of the embryonic clefts; finally, 
to stretching of cell-groups in the course of embryonic growth. 

None of these theories explains all the arrangements which have 
been noted; and the terms of nervous, zoniform, metameric, uni- 
lateral, etc., nevi, are not justified. The same remark applies to the 
term ichthyosis hystrix. 




Fig. 



-Linear hyperkeratotic nevi, very numerous, in a girl aged seven years. 
Service of Dr. Variot. 



The linear nevi, instead of being hyperkeratotic, may suggest 
simple papilloma, psoriasis, or lichen; they may be hairy, pig- 
mentary and so forth. 

Not all linear dermatoses are necessarily nevi; in rare instances, 
genuine cases of lichen planus, psoriasis, eczematides, prurigo 



208 KERATOSES 

vulgaris, etc., are observed which assume a topography like the 
linear nevi, appearing at any age and subsiding on appropriate 
treatment. 

Flat Senile Warts (Verruca Plana Senilis). — These keratotic ele- 
vations, also known as seborrheal warts, have the following char- 
acteristics: 

They are rounded or oval, sometimes irregular, from the size of 
a lentil to that of a green almond, more prominent in the center 
than at the periphery, distinctly circumscribed, sometimes actually 
overhanging, covered with an adherent horny and fatty layer, of 
variable thickness, of a gray, brown or black color. After this coat 
lias been removed by washing with soap, maceration, or rubbing 
with ether, a mammillated, honeycomb or cauliflower-like sur- 
face with furrows is exposed; the consistence is molluscoid or 
granular. 

Senile warts, generally numerous on the same individual, pre- 
ferably occupy the flanks, the belt-line, the back, the chest, the 
neck, the shoulders; many hundreds of them may be counted; they 
are less frequently observed on the forehead, the temples and the 
cheeks. They develop after the fortieth year of life, especially in 
women; they may begin before the age of thirty. They persist and 
multiply with the advance of years. 

Histology shows either hypertrophy of the epidermis or atrophy 
through invasion of the horny layer, but always some irregu- 
larity; the papillae are deformed and twisted. Horny pearls are 
often found in the interpapillary depressions. A special lesion, 
described by Pollitzer, consists in a peculiar arrangement in whorls 
of the Malpighian cells at certain parts. The hairs and glands are 
atrophied; there is no true seborrhea. The subjacent cutis is often 
in a state of senile degeneration, but presents no inflammatory 
infiltration. 

Their clinical features, their structure and their seat, everything 
differentiates senile warts from the patches of senile keratosis with 
which they are too often confused. They have not the same tendency 
as the latter to undergo epitheliomatous transformation. 

I consider them as delayed nevi, and they actually coincide 
frequently with vascular nevi, fibroma molluscum, or pigmentary 
spots. There is no connection as regards etiology and character 
between senile warts and ordinary warts. 

Treatment is instituted only on special request; mercurial oint- 
ments, collodimn with salicylates or sublimate, black wash and even 
strong caustic agents may be recommended. It is much more advis- 
able, however, to resort to the galvanocautery cautiously handled 
and combined if necessary with curettage; no perceptible cicatrix 
must be produced. Radiotherapy seemed to me to be inefficient. 



CIRCUMSCRIBED KERATOSES 209 

Electrolysis is very successful, but the method is much too laborious 
in its application. [Destruction by means of carbonic acid snow may 
be employed.] 

Keratosis Senilis. — The usually multiple and scattered keratotic 
spots which are observed especially on the face of aged individuals, 
were formerly known under the names of "crasse des vieillards" 
acne sebacee, etc. They seem to me to constitute a complication 
of senile degeneration of the skin and frequently lead to multiple 
epitheliomatosis (p. 685) ; from this viewpoint, they constitute an 
obvious type of precancerous dermatosis. 



A 


B r 
















i 1 

; 










D 

) 


\\\.W/g 


•i;. 




\ \ ^ 


-v---: - 


-^ 


-W 


p^att 


, 'Wr-' \ 










Si 




















- " J * < i 


-■:<<,:■'■ : \£S^ 












'•=.' 


Mr 


i . '" 




\ 




1% ■ • 

F 


Sir 

G 


1 

H 


I, 


. tiAfV** 



Fig. 64. — Histology of senile keratosis. The section comprises the border of 
a fairly extensive keratotic spot from the temporal region of an old man. A, 
edema; B, epidermic globe; C, hyperkeratosis; D, sebaceous gland; E, elacin; F, hair 
follicle; G, plasmatic infiltrate; H, elacin; I, plasmatic infiltrate. X 37. 

The lesions of senile keratosis begin as dry yellowish or brownish 
spots, or as warty elevations somewhat resembling seborrheal 
warts, or again as irregular but fairly well outlined telangiectatic 
red spots. Gradually they become covered with a gray or brownish 
keratotic coat, friable or of dry consistence, with a wrinkled surface 
which may bristle with irregular elevations. This very adherent 
keratotic layer sends conical processes into the derma; its detach- 
ment often gives rise to small hemorrhages; the changes become less 
marked toward the borders of the spots; the skin in their center 
may be atrophic or cicatricial. 
14 



210 KERATOSES 

Senile keratoses appear more or less soon after the fiftieth year in 
very variable numbers, notably on the forehead, temples, nose, 
cheeks, the back of the hands and wrists, sometimes on the neck 
and the forearms. As a rule, they persist indefinitely and increase 
in number, but they may disappear. 

Their evolution into epithelioma is by no means necessarily fatal. 
This is indicated by a transformation of the keratotic layer into a 
crust, ulceration of the subjacent derma, at first superficial, and 
the appearance of epitheliomatous pearls at the circumference. 

Histology shows in the first stages an irregular hyperkeratotic 
horny layer, provided with conical processes on its inferior sur- 
face; a thinned mucous body, sometimes infiltrated with wander- 
ing cells; an irregular and edematous papillary body. The corium 
presents to a high degree the lesions of senile dystrophy, namely 
the transformation of the elastic tissue into basophilic elacin, and 
a colloid change of the connective-tissue strands; perivascular tracks 
of cellular infiltration are seen, with a predominance of plasmocvtes 
(Fig. 64). 

The differential diagnosis must be made from the various nevi, 
syphilides, psoriasis, rosacea, especially from lupus erythermatodes. 
The patient's age and the location of the lesions are factors of 
prime importance. 

Treatment with salves and ointments containing keratolytic and 
keratoplastic medicinal agents is often not particularly efficient. 
Radiotherapy accomplishes frequently, though not invariably, a 
complete disappearance without pain. The galvano-cautery, assisted 
by curettage, yields excellent results. 

In presenile dystrophy, in xeroderma pigmentosum, in radioder- 
matitis, and in cutaneous arsenic poisoning, practically identical 
keratoses in spots and warty elevations may occur; these dystro- 
phies belong to the same natural group. 

Gonococcal Keratoma. — A very rare variety of disseminated 
keratosis has been described under the name of " blennorrhagic 
keratoma" by Yidal, Jacquet, Jeanselme, Chauffard, and others. 
Certain cases of gonorrhea, confined to bed on account of severe 
arthropathies or myelopathies, present hard yellowish conical 
elevations, comparable to drops of yellow wax or upholsterer's 
tacks, scattered over the limbs and sometimes on the trunk. There 
may be an erythematous border at the circumference. 

Genuine carapaces of hyperkeratosis have been observed in the 
palmar and plantar regions. These products disappear in two or 
three months under simple attention to cleanliness. 

Porokeratosis.— The porokeratosis of Mibelli (1893) and Respighi 
is a rare affection, characterized by irregular circulate spots, the 
area of which is atrophic, scaly or normal, with a papular border 



KERATODERMA 211 

marked by a horny plate; this plate is imbedded in a "trench," or 
groove from which it rises in the form of a prismatic crest. The 
lesion begins with a horny cone wedged in a papule which slowly 
spreads out. The lesions are situated especially on the extremities, 
the face and the genitals; they have been observed in the buccal 
mucosa. 

Porakeratosis is often familial, but nothing more is known con- 
cerning its etiology. Truffi associates it with the nevi. Mibelli 
assumes a primary epidermal dystrophy of the glandular orifices, 
more particularly of the sweat-pores. 

The porokeratosis of Italian authors must not be confused with 
the punctiform keratosis which will be briefly referred to in-the fol- 
lowing and which the majority of writers also call porokeratosis. 

KERATODERMA. 

I employ the term keratoderma for the palmar and plantar 
keratoses. 

The skin of the palmar and plantar regions has a special structure. 
It is predisposed to hyperkeratosis and in this case has a tendency to 
crack, forming very painful fissures in the flexion folds. All dry 
dermatoses in this locality assume an analogous appearance, which 
renders the diagnosis rather difficult. 

Some keratodermas are essential, representing malformations; 
others are symptomatic, the result of repeated traumatisms, intoxi- 
cations or localization of various dermatoses. 

Essential Keratodermas. — Familial keratoderma, or Meleda disease 
[keratoma palmare et plantare] is an ordinarily congenital, some- 
times acquired affection, which frequently attacks several chil- 
dren of the same family and has a marked tendency to hereditary 
transmission. 

The palmar aspect of the hands and fingers (Fig. 65), the plantar 
aspect of the feet and toes, are symmetrically and as a whole, the 
seat of a horny thickening. The borders are marked by a purplish 
or bluish-pink edge from 4 to 5 mm. wide. 

The hyperplastic horny layer may be smooth, soft, of a waxy 
or brownish-yellow hue, made up of large very adherent lamellae. 
In this case a local hyperidrosis is frequently noted which is regarded 
by Lenglet as the initial phenomenon and the hyperkeratosis itself 
is supposed to originate at the sweat orifices. I have sometimes 
noted the presence of intracorneal bullae with turbid contents. 

In other cases, the hyperkeratosis is dry, hard, roughened, of a 
thickness which may reach a centimeter ; it is fissured in the folds, 
or divided into polygonal blocks. 

The underlying skin is invariably red, usually tense, sclerotic 



212 



KERATOSES 



and atrophic Tn well-marked forms, it is so much retracted at the 
last phalanges that the fingers arc conical and tapering, as if enclosed 
in a very tight-fitting, yellowish and horny case; the nails are 
thinned and the nail bed is bloodless. 

The movements of the hands and fingers are impeded and painful; 
walking is difficult. 

The lesions almost invariably encroach upon the anterior aspect 
of the wri>t> and along the Achilles tendons; the knees, elbows and 
articular folds may present thick, warty, aberrant patches, of a 
brownish-red color, distinctly circumscribed, with dilated and 
blackened pores. These patches may progress and extend, as 
shown by casts preserved in the Museum of the St. Louis Hospital, 
taken at intervals of ten years on the same patient. 




Fig. 65. Hand of 



ing girl, aged thirteen years, with congenital symmetric 
palmar and plantar keratoderma. 



Familial keratoderma is met with either isolated, or associated 
with generalized ichthyosiform hyperkeratosis, of which itrepresents 
merely a localized variety; in its course it resembles symmetrical 
erythrokeratoderma with which it may coincide. 

When essential keratoderma is not strictly congenital, it may 
develop between the first months of life and the second year, or 
even in late childhood. The onset is not easily discovered; it is 
preceded by redness, hyperidrosis and exfoliation in hue lamellae. 

The cases of delayed appearance are distinguished by several 
authors under the name of symmetrical keratoderma of adults, 
acrok'erai 'inn, or essential tylosis. The term of M61eda disease comes 
from an island in the Adriatic, where Neumann and Killers found 
this malformation to be endemic. In the non-hereditary cases, the 
origin has been referred to consanguinity of the parents. 



KERATODERMA 213 

Palmar hyperkeratosis is serious on account of its incurable 
character and the resulting inconvenience, but the condition is 
considerably relieved by moist or rubberized dressings and by kera- 
tolytic agents. Radiotherapy, which constitutes the best treatment, 
has led to noteworthy improvement, but to no complete cure in 
my experience. 

Symptomatic Keratodermas. — Occupational Keratoderma. — This 
results from friction, pressure or various physical and chemical, 
chronically repeated irritants, and represents a sort of diffuse callus. 
The lesions are unilateral or symmetrical and their distribution is 
often characteristic of certain occupations. 




Fig. 66. — Arsenical keratosis. The illustration shows keratotic patches, similar 
in type to others situated over the forearms, face, scrotum and legs, interspersed with 
hyperpigmentations and several true epitheliomata. In addition, there occurred a 
symmetrical keratoderma of the palms and soles. The disease was of twenty-five 
years' duration and due to drinking water charged with arsenic. (Ormsby.) 

Arsenical Keratosis. — Arsenical keratosis, a consequence of 
chronic arsenic poisoning, is localized especially on the hands and 
feet. It is often preceded by formication and attacks of desqua- 
mative or bullous erythema. It persists indefinitely, even if the 
arsenic medication is stopped. 

It manifests itself under two forms which are sometimes asso- 
ciated: (1) A diffuse yellowish scurfy thickening of the palmar and 
plantar regions, with well-marked papillary crests; (2) verrucous 
protuberances which occur in large numbers on both surfaces of 



214 



KERATOSES 



tli 



the extremities, sometimes also the face and neck and which may 
degenerate into arsenical cancer. 

Eczema Keratoticum. — The most common kerato 
referable to eczema and to syphilis. 

Keratotic eczema or corneal eczema of Wilson 
metrical and often of occupational origin. It may be partial or 
extend over almost the entire region (Fig. 67) and is characterized 
by its diffuse imperfectly marked borders which pass imperceptibly 



nas are Those 



is usually svm- 




I'hnt.'ir kcfiiliitic cc/.cnm. 



into the healthy skin. It has a tendency to spread along the large 
grooves. The thickened horny layer splits and becomes exfoliated 
in lamella 1 , exposing a reddened skin, where vesicles are rarely 
observed. The histological lesions are those of eczema. Foci of 
eczema or eczematides, are encountered elsewhere, especially on the 
scalp. The duration of this affection is sometimes several years, 
with remissions and relapses. It is treated with keratolytic agents 



KERATODERMA 



21! 



followed by reducing agents; radiotherapy is sometimes very 
effective. 

Palmar and Plantar Psoriasis. — Palmar and plantar psoriasis is 
usually symmetrical and accompanied by a scattered eruption, but 
it may be isolated, affecting only a single extremity. It consists 
at the onset of hyperkeratotic yellowish spots which are distinctly 
outlined and promptly become exfoliated in dry, friable lamellse 
under which the bright red skin is seen. The spots which have 




Fig. 68. — Genuine palmar psoriasis. 

rounded and clearly outlined contours become confluent in poly- 
cyclic patches (Fig. 68). The appearance may be extremely sug- 
gestive of syphilis or trichophytosis, but it is rare for these spots 
not to extend, as manifest patches of psoriasis, to the wrists or to the 
dorsal regions of the hand, the fingers, or the feet, or for no other 
spots to appear in different parts of the integument — which clinches 
the diagnosis. Biopsy shows the characteristic lesions of psoriasis. 
In this particular localization, psoriasis requires very energetic 
treatment; sometimes it subsides spontaneously. 



21G KERATOSES 

In pityriasis rubra pilaris, the palms and soles are diffusely red- 
dened, dry, hyperkeratotic and thickened, but desquamation is 
slight. 

Lichen planus gives rise either to small, dry, horny papules, or to 
depressed more or less confluent keratotic spots (Fig. 23), or to red 
and finely scaly patches — or finally to total keratoderma. 

Gonococcal Keratoderma. — Gonococcal keratoderma manifests 
itself in the form of horny soles, sometimes a centimeter thick, or as 
hyperkeratotic or crusted acuminate papules, surrounded by a dark 
red halo; it affects the plantar and palmar regions, the back of the 
feet, the lower limbs, sometimes the genitals and exceptionally 
the upper limbs and the trunk. This affection, which is very 
uncommon, has been observed especially in connection with gono- 
coccal rheumatism. 

Palmar and plantar trichophytosis, elucidated by the work of 
Djellaleddin Moukhtar, is not, strictly speaking, a keratoderma, but 
must be mentioned from the diagnostic viewpoint. It appears as 
perfectly round or polycyclic red spots, surrounded by an epidermic 
collar. Small vesicles may be discovered on their area and around 
their circumference. The mycelium is abundantly present in the 
vesicular fluid and in the scales. 

Epidermophytosis of the same regions, more recently discovered, 
is relatively frequent and presents a variety of aspects. It is there- 
fore essential to keep in mind the imperative necessity of micro- 
scopical examination in all more or less doubtful cases. 

The reader is reminded that in the course of dysidrosis, or of the 
pyodermatitides which are sometimes so obstinate in the palmar 
and plantar regions (continuous- acrodermatitis), a clinical picture 
suggestive of various keratodermas is sometimes seen. 

The appearance of so-called punctiform keratosis (porokeratosis 
of some writers), characterized by small, sometimes very hard, 
scattered or grouped, miliary horny masses, may be produced, with 
slightly variable modifications, by an entire series of skin affections : 
lichen planus, follicular dyskeratosis, warts, keratotic nevi, familial 
or arsenical keratoderma, etc. 

The psoriatiform palmar and plantar syphilides, also erroneously 
named syphilitic psoriasis by some authors, are the most important 
of all the keratodermas. Bazin grouped nearly all the lesions 
enumerated above under the heading of palmar arthritides, in order 
to contrast them with syphilides in the same locality. 

These syphilides are relatively common, they may appear at any 
date between the third month following the infection and the most 
remote tertiary stages. They resemble each other so closely that it 
is not always possible to distinguish the premature from the late 
forms; the latter are described by A. Fournier as "delayed secondary 



KERATODERMA 217 

manifestations." Nevertheless, although certain pictures do not 
indicate the age of the syphilitic infection, there are others belonging- 
more particularly to one or other of its stages. 

In the secondary stage, multiple lesions are especially met with, 
consisting either of flat lenticular papules of a dusky red color, slightly 
keratotic and scaly, or of depressed nummular spots, surrounded by 
a keratotic ridge (Fig. 69) ; in the tertiary stage and in hereditary 
syphilis tarda, round or polycyclic spots of a dark or coppery 



H^^Hjiji^fj^gJnj^^^H 



Fig. 69. — Early secondary palmar syphilide, contemporaneous with the roseola. 

red, single or in small numbers, are more usually seen, which may 
be markedly hyperkeratotic, or wrinkled and cracked, sometimes 
bordered by tubercles (Fig. 70). 

These various lesions are found on any part of the palmar surface 
of the hand or fingers or the soles of the feet. Though not absolutely 
diagnostic, a unilateral character of the lesion is somewhat more 
frequent in tertiary and hereditary syphilis. 

The diagnosis rests on the sharp limitation of the spots; on~ 
their margin of hyperkeratosis with a central depression; on the 



21S 



KERATOSES 



infiltration of the base, which is of greai value when demonstrable; 
finally, on the slight tendency of the lesions to encroach upon 
the neighboring regions. It goes without saying that the ante- 
cedents, the co-existence of other symptoms of syphilis, and the 
Wassermann reaction must be taken into consideration. 




i it. Late palmar syphilide. 



These syphilides are often obstinate and recurrent. Treatment 
with calomel injections, or preferably arsphenamin, often accom- 
plishes their rapid removal, while all other less forcible measures 
generally fail. Local treatment, with mercurial or with salicylic 
acid plaster may serve as a useful adjuvant. 

Moreover, in all keratodermas, one must never neglect to soften 
and remove the horny layer (by means of moist dressings, inunction 
with potash soap, or salicylic acid preparations), in order to open 
the way for or otherwise assist the special medication that is 
indicated. 

KERATOSIS OF MUCOUS MEMBRANES. 

The mucosa of the buccal cavity and the genital organs possess, 
like the skin, a papillary body and a Malpighian layer, but the 



Keratosis of mucous membranes 219 

granular layer is absent in the latter and the keratinization of the 
superficial layers is incomplete. 

The lining of the red border of the lips, that of the prepuce and 
glans, as well as that of a large portion of the vulva, has a structure 
related to that of the epidermis, so that these surfaces are called 
semi-mucosse. 

Under pathological conditions, these mucosae and semi-mucosse 
may become the seat of white spots or patches due to the appear- 
ance in their epithelium of a great abundance of keratohyalin and 
eleidin and a genuine keratinization. The term of keratosis is justi- 
fied in these cases. 

Leukoplakia. — This affection, which is also known as leukokera- 
tosis, white spots of smokers — and erroneously called buccal 
psoriasis, tylosis lingua, buccal ichthyosis, etc. — is the most common 
form of keratosis of mucous membranes. 

Symptoms. — Leukoplakia is almost invariably located in the mouth, 
exceptionally in the genital regions. In the mouth, it is usually the 
tongue, on its anterior half, which is involved to the highest degree. 
In some cases, the lesions predominate on the lateral portions of the 
back of the tongue, in others on the margins or the middle; or again, 
the upper surface of the organ is affected as a whole; the lower 
surface is less commonly invaded. 

More frequent, but as a rule not so marked, is a localization of 
the disease on the internal aspect of the cheeks, in the form of a 
symmetrically arranged triangle; representing the commissural 
white spots of smokers. The posterior region of the cheeks, the 
gums and the palate, are not often attacked by leukoplakia, which 
is altogether exceptional in the pharynx and larynx. 

On the lips, leukoplakia occupies the posterior surface, the free 
margin, the external red surface, sometimes the commissures, or all 
these regions as a whole. 

In women, leukoplakia may be observed on the vulva, notably 
on the inner surface of the labia majora, on the labia minora, the 
prepuce, the clitoris, the vestibule, sometimes in the vagina and 
around the anus. In men, leukoplakia of the prepuce and glans 
is rather rare. 

The lesions begin with a smooth condition of the mucosa, which 
is reddened or of an opaline hue. Once established, they assume 
two different aspects, according to the severity of the case. 

Mild leukoplakia is characterized by obliteration of the papillae 
and the grooves of the mucosa, which shows a whitish, grayish, 
bluish or white color, indicative of a change in the transparency of 
the epithelium. Exceptionally large pinkish papillae may be seen 
shining through this smooth whitish veneer. 

The lesions are arranged in spots or patches of extremely variable 



220 KERATOSES 

dimensions, irregular configuration, sinuous, festooned or ragged 
margins, sometimes sharply outlined, sometimes gradually fading 
into the normal state. The entire leukoplasic surface may present a 
uniform appearance or the center may be more opaque and thick- 
ened. The confluence of these spots gives rise to patches, unevenly 
checkered in dark red, gray or white. The keratotic layer, which 
is always very adherent, cannot be removed by scraping, without 
exposing the submucosa; but it is apt to desquamate in small opaline 
shreds, which on the lips, for instance, the patient can pull off with 
his teeth. 

The severe or marked form of leukoplakia is connected by inter- 
mediate stages with the mild type. The thickening of the mucosa 
and of its horny coat may become considerable. Either on an 
already leukoplasic surface, or on a healthy basis, hard, inelastic, 
pearly or snow-white patches make their appearance, several centi- 
meters thick with gently sloping or steep borders, with a smooth or 
roughened surface, closely adherent to the underlying tissues. They 
may become detached spontaneously, at intervals of months or 
years, but are promptly reproduced. The entire tongue is sometimes 
held in a cracked "cardboard" leukoplasic case. The cheeks, the 
vulva, or the glans penis may also be covered with a coat of this kind. 

The keratotic patches are often furrowed by folds or fissures; 
more rarely, they are studded with acuminated horny protuberances. 
This verrucous variety is especially noteworthy as being frequently 
the prelude to epitheliomatous changes. 

Another complication of leukoplakia, inconvenient and trouble- 
some rather than actually serious, is an obstinate ulceration which 
I have named leukoplasic ulcer and which will be discussed else- 
where in this book (p. 307). 

The condition of the mucosa underlying the leukoplakia is difficult 
to determine. In the case of the tongue, it is as a rule sclerotic and 
even retracted proportionately to the hyperkeratosis, either super- 
ficially or deeply, as a result of the syphilitic sclerotic glossitis which 
i^ the ordinary substratum of the severe leukoplakias. Elsewhere 
it is often in a more or less marked state of atrophic sclerosis. 

The subjective sensations — which are absent in the mild forms of 
the disease — consist of an impairment of mobility and an unpleas- 
ant sensation of dryness and hardness in the severe cases; acute 
tenderness and shooting pains usually appears only as the result of 
fissures. 

Vulvar Leukoplakia carefully studied by Jayle and Bender — 
does not differ from the same disease as seen in the mouth. It may 
affect the vaginal mucosa and very rarely the uterine cervix. It 
may precede or accompany kraurosis or sclerotic atrophy of the 
vulva, with which it has been confused. 



KERATOSIS OF MUCOUS MEMBRANES 221 

The course of leukoplakia is altogether irregular. It usually pro- 
gresses slowly and persists throughout life. It may remain entirely 
stationary under the influence of proper hygiene, or it may even 
subside and disappear, at least partially; but it is very prone to 
recurrence. 

Leukoplakia and Cancer. — The gravity of leukoplakia is due to its 
complications, which are frequent and very dangerous. Fissures, 
cracks and erosions are very common in the vicinity of carious 
teeth or as the result of faulty hygiene; they give rise to acute radia- 
ting pains and may lead to lymphangitis or to suppuration. 




Fig. 71. — Cancer (lobulated epithelioma) on leukoplakia of the tongue. 

Epithelioma, however, constitutes the real danger of leukoplakia. 
It may supervene in all the forms, especially the most severe types, 
and at any stage of the leukoplakia. Its relative frequency has been 
variably estimated at 30 and even above 50 per cent, of the cases; 
a ratio of 15 to 20 per cent, seems to me nearer the truth. [This 
estimate which seems to me very high applies, of course, only to 
the severe cases.] The physician may save his patient from an 
awful death, such as supervenes in cancer of the tongue, if he 
manages to discover in time the incipient complication and is 
sufficiently energetic and convincing to obtain consent to a timely 
operation. 



222 KERATOSES 

Cancer of the tongue on a basis of leukoplakia (Fig. 71) is almost 
invariably of the lobulated or spinocellulare type and of the variety 
which I call cancroid: exceptionally, it is of the tubular type. It 
has two principal modes of onset. 

In most cases it begins with a circumscribed, lenticular or more 
extensive papillomatous elevation, often encircled by a keratotic 
margin, with a very slightly indurated base; under this superficial 
form it spreads on the surface during a few weeks, a month or two, 
before invading the depths of the tissues, so that prompt operative 
interference is not infrequently successful. 

More rarely the epithelioma develops deeply from the start, 
originating from a fissure which has persisted one or two weeks and 
at whose level palpation reveals a minute circumscribed woody 
induration. In these cases, surgical intervention can hardly come in 
time. Leukoplasic ulcers only exceptionally give rise to cancer. 

On the lips, cheeks and genitals, epithelioma appears under 
entirely similar conditions. 

I have emphasized for many years the line of conduct to be fol- 
lowed when cancer is suspected in the course of a leukoplakia; and 
increasing experience causes me to be more and more positive in this 
respect. 

What should not be done, is: ( 1 ) to wait until the symptoms become 
more pronounced, the epithelioma develops and the glands become 
enlarged; (2) to resort to an antisyphilitic "therapeutic test" which 
causes the loss of valuable time; (3) to irritate the suspicious lesion 
with cauterization of any kind, diathermia, etc.; (4) finally, to try 
radiotherapy or radium, which are inefficient or even harmful in 
these cases. 

What .should be done: in all cases where the diagnosis is not abso- 
lutely certain, a specimen removed from the living subject should 
be at once examined under the microscope, a step which will provide 
a definite answer in less than twenty-four hours; or, when cancer is 
known to exist, to proceed at once and without delay to the surgical 
extirpation of the lesion, which affords the only prospect of salvation. 
[The rich lymphatic tissue of the tongue increases the risk of dis- 
semination as a consequence of the manipulations inseparable from 
biopsy. After biopsy, therefore, a delay of even twenty-four hours 
may have serious consequences. In my opinion, the complete 
operation, whenever possible, should follow immediately on the estab- 
lishment of the diagnosis which should therefore be made on frozen 
sections, with due consideration of the difficulties of this method.] 

Pathological Anatomy. On a leukoplasic mucosa ( Fig. 72) the rete 
Malpighii is greatly thickened (acanthosis) and its interpapillary 
plugs are hypertrophied in all directions; between the mucous body 
and the extremely thick horny layer which covers it, and which 



KERATOSIS OF MUCOUS MEMBRANES 223 

consists of cells deprived of their nuclei, a granular layer has made 
its appearance, with very abundant keratohyaline and eleidin, 
diffusing into the stratum corneum; these lesions explain the white- 
ness of the patches. 

In the papillary body of the corium is seen a variable infiltration of 
round cells around the vessels, as well as sometimes the lesions of 
endo-peri vasculitis and connective-tissue sclerosis. 



B 

1 


c 


A ' 


i 


I . ,.■+ / 1 j . \\ 




^«^-, 3 :/. /■'•' ■ w "'V-;--. v ^.^- v .-=: ■'"' ^ \J \ / 




• / . . ■:. ;. mm 

: ' i : .; : 





Fig. 72. — Simple and verrucous leukoplakia of the tongue. Under the epithe- 
lium, which is greatly thickened and abundantly provided with keratohyalin and 
diffuse eleidin, is seen an inflammatory cellular infiltrate, especially abundant at 
the level of the verrucous portion; a newly formed layer of sclerotic tissue, traversed 
by numerous dilated bloodvessels, has become interposed between the epithelium and 
the muscular tissue. No trace of epitheliomatous change is demonstrable. A, simple 
leukoplakia; B, eleidin; C, verrucous leukoplakia; D, muscular tissue; E, sclerosis; 
F, inflammation. X 18. 

When epitheliomatous transformation occurs, it results from 
atypical budding of the interpapillary processes or of the epithelium 
which lines the fissures (Fig. 192). Invasion of the lymph spaces 
takes place very rapidly, especially in the tongue. 

Etiology. — Leukoplakia is at least ten times more frequent in 
men than in women. It is observed especially from thirty to fifty 
years of age, but cases have been reported at the age of twelve years 
(Benard) or even younger. I have encountered it, complicated by 
cancer of the tongue, in a girl of nineteen years, which is excep- 



224 KERATOSES 

tional from every point of view. Leukoplakia may result from multi- 
ple causes of different kinds. The equation: 

Leukoplakia = syphilis + tobacco 

although often true, is certainly too absolute. Tobacco is the most 
powerful of the local causes; but dental lesions, false teeth, abuse 
of alcohol and condiments, etc., also play a part in the production 
of buccal leukoplakia, especially in non-smokers and in women. 
Other irritants intervene in genital and anal leukoplakia. 

In the great majority of the cases, leukoplakia develops on a 
syphilitic soil, but I believe that, even on the plea of hereditary 
syphilis, it is not justified to consider it as an invariably para- 
syphilitic affection, as maintained by Professors Landouzy and 
Gaucher. There are cases where syphilis is absent, where the 
Wassermann reaction is negative and where nothing can be sus- 
pected except local irritative factors, obscure auto-intoxications, or 
perhaps an individual predisposition. 

At the present state of our knowledge it is impossible to say if 
it is correct to recognize a syphilitic leukoplakia, and other nicotine, 
dental, post-infectious leukoplakias, differing by their symptoms 
and their course, or if leukoplakia is a syndrome resulting from 
various causes, a modification of the epithelial evolution resulting 
from infectious or toxic vascular lesions. The last-named theory 
is the most probable in my opinion. 

Treatment. — This must be carefully handled and requires in the 
first place a strict buccal hygiene: absolute abstinence especially 
from tobacco, from alcohol, condiments and highly spiced foods, 
irritative mouth-washes; the teeth must be put and kept in perfect 
condition. 

Soothing or weakly alkaline irrigations of the mouth with Vichy 
water, or Saint Christau water, are useful palliatives, preferable to 
pastils and compressed tablets. The warm mineral springs of 
Sainl Christau, with local spraying, or to a less degree, various 
sulphur springs, yield favorable results. 

Among topical applications, those most to be recommended are 
glycerol salves or ointments made with balsam of Peru, oil of cade, 
oil of birch, or salicylic acid. In case of thick keratotic patches, 
their detachment may be furthered by painting with acid nitrate of 
mercury, chromic acid, or potassium bichromate, etc. Sometimes, 
the destruction of certain patches with the thermocautery, or their 
surgical removal, may be called for. In a general way, however, 
caustics arc not /<> he trusted, especially in case of fissures, which 
patients like to treat and abuse with silver nitrate; cauterizations 
are certainly more injurious than useful. Radiotherapy and radium, 



KERATOSIS OF MUCOUS MEMBRANES 225 

energetically employed, have a few cures to their credit, but on the 
other hand a large number of failures are on record. 

The operative indications in case of probable or certain cancer 
need not be repeated here. 

General treatment with antisyphilitic agents, is evidently required 
in the presence of specific antecedents or a positive Wassermann 
reaction; but it has been found effective even in cases where 
syphilis was apparently excluded. Intragluteal calomel injections 
exert such a preponderating action in leukoplakia that they were 
accorded the preference until the introduction of arsenobenzol ; 
the latter is still more active, especially in combination with 
soluble mercurial injections. In obstinate cases, I have often 
been excellently served by local treatment with injections of very 
dilute cyanide of mercury. Iodides are not to be recommended. 
When an established leukoplakia in a syphilitic patient has only 
partially yielded to specific treatment, or resisted it, the advantage 
will at least have been served of opposing the extension of the dis- 
ease and preventing the appearance of other syphilitic manifestations. 

General hygienic recommendations must not be neglected, 
especially in regard to diet, correcting dyspepsia if necessary, or 
controlling any auto-intoxications which may have been discovered. 

There is a certain class of leukoplasic patients whose life is made 
miserable by a regular "cancerophobia," liable to be maintained 
by treatment of any kind. In these cases, a judicious psychotherapy 
is indicated. 

Syphilitic Glossitis. — It seems to me useful to describe in connec- 
tion with leukoplakia the lesions which secondary and tertiary 
syphilis so frequently produce upon the tongue. This organ may 
present : 

1. The smooth patches of Fournier; "mowed-lawn patches" of 
Cornil. These are pinkish spots, devoid of papillse, dry, non-indur- 
ated, round or oval, distinctly outlined, though without special 
border. These lesions may be premature, developing rather rapidly, 
or delayed, and in this case are much more obstinate. 

2. Opaline mucous patches seen only on the margins or at the tip 
of the tongue, generally near carious teeth; sometimes they are 
eroded or fissured; rarely, on the back of the tongue, they are 
papular or lozenge-shaped. 

3. Hypertrophic or papillomatous papules, with a gray or reddish 
surface, very rare, occupying the vicinity of the circumvallate 
papilla? where they become confluent in a large patch; from here 
they reach the back of the tongue, which then assumes the appear- 
ance called "toads' back." 

4. Tuber culo-ulcerative syphilides and gummas, which will be dis- 
cussed elsewhere; these may leave sclerotic cicatrices. 

15 



22ii 



KERATOSES 



5. Finally, sch n tic glossitis, of the tertiary period, very common, 
especially in men; it may be superficial or deep. 

In the superficial form there are a few islands of cortical sclerosis, 
or a single smooth red surface, with lamellar induration, sometimes 
complicated by fissures. 

Dei "p glossitis, occupying especially the middle or the borders of 
the tongue, or its entire anterior half, is characterized by an 
irregular lobulation, prominent papillae being separated by deep 
grooves united in a network: fibrous induration of the organ is also 
demonstrable Fig. 73). 'Die mucosa is wine-red in some places, 
discolored in other-, smooth, tense, practically devoid of papilla? 
throughout. 



Fig. 7'.',. — Sclerot 




ijred 



ssitis of the deep variety, in a woman 
ixty years. 



The coexistence of syphilitic lingual sclerosis and leukoplakia is 
very common. 

Sulcated or Scrotal Tongue. Sclerotic glossitis must not be con- 
fused with ;t congenital, often familial, malformation which bears 
this name. The organ in such cases is lobulated and fissured; its 
very villous surface is studded with prominent fungiform papillae. 
But its consistence is soft, there is no pain and the condition is 
absolutely permanent. 

Median Rhomboidal Glossitis. -This affection was described in 
January of 1914 by Brocq and Pautrier; it is not rare and I have 
seen numerous instances. The dorsal asped of the tongue, in front 



KERATOSIS OF MUCOUS MEMBRANES 227 

of the circum vallate papillae presents a reddish raw surface; the 
lesion is usually mammillated, slightly indurated, indolent, and 
extremely persistent. Anatomically, nothing is found but hyper- 
acanthosis and a moderate infiltration of the corium. This glossitis, 
which occurs especially in adults, is often wrongfully ascribed to 
syphilis; its nature is unknown; it resists all local or general treat- 
ment. 

Lichen Planus of Mucous Membranes. — This is very commonly 
confused with leukoplakia or with syphilides. Its diagnosis never- 
theless is relatively easy. 

Lichen planus of the^mucosse, especially of the mouth, is not rare. 
It is observed in about one-half of all lichen cases. It may persist 
beyond the cure of the cutaneous manifestations, or it may consti- 
tute a primary and sometimes exclusive localization. Familiarity 
with its characteristics is therefore necessary. 




Fig. 74. — Lichen planus of the tongue in a man aged forty-two years. 



The seat of election of lichen planus of the mucosae is in the first 
place on the internal aspect of the cheeks, at the level of the alveolar 
margin, preferably opposite the last molars. It manifests itself on 
one side, or symmetrically, in form of one or several white patches 
with an irregular reticular or annular arrangement resembling lace- 
work, pure white or bluish in color, on a normal background; the 
more or less delicate network is crossed by larger bars. Erosion 
or desquamation never occurs. 

Next in order is the localization on the tongue (Fig. 74), which 
may present either patches of a dull bluish white, smaller than a 
lentil, with a reticular or fern-leaf design, or opaline surfaces 
through which a few rose colored papillae project. 



228 KERATOSES 

Lichen planus may furthermore be met with on the lips, palate, 

gums, tonsils, on the glans and prepuce, where it is often annular, etc. 

These lesions are absolutely sluggish and indolent; they persist 

for months, or oftener for many years, undergoing very gradual 

changes. 

Histology shows a thickening of the epidermis in all its layers, 
the appearance of a stratum granulosum, dome-shaped papilhe, 
and a cellular infiltration in the papillary body. The structure is 
accordingly entirely that of lichen planus of the skin. The explana- 
tion of the white color i> the same as for the network of the cutaneous 
papules of typical lichen planus; it moreover assumes an identical 
form in the majority of cases. 

The treatment of lichen of the mucosae need not be very active, 
the condition being obstinate but by no means serious. It never 
leads to cancer. Soothing mouth washes, inunction with balsam of 
Peru, painting with potassium permanganate, 1 to 100, are quite 
sufficient. High frequency currents and radium therapy have not 
yielded favorable results in my experience. A bland diet, good 
hygiene, a quiet life, arsenic internally, are recommended. 

Lupus Erythematodes. — It is exceptional for lupus erythematodes 
to affect the mucous membranes. It is sometimes seen to radiate 
in the form of a scaly redness on the posterior aspect of the lower 
lip starting from the free border. When it develops on the internal 
aspect of the cheeks or on the tongue, it manifests itself in the form 
of a circumscribed patch, mottled with white and bright red, and 
partly atrophic. 

Smooth Patches of the Tongue.— Occasionally, the tongue is seen 
to present >pot> or large patches devoid of papilhe, reddish and 
glistening, without a white margin, absolutely stationary during 
months or years. They are entirely indolent and the patient may 
be unaware of their existence. In other cases, they are very sensitive, 
and associated with ghssodyniu. 

These patches arc always suggestive of the cropped patches of 
sj philis, or of incipient leukoplakia. I am personally convinced that 
they may be referable to a variety of causes, notably tuberculosis, 
diabetes, chronic dyspepsias, severe neuropathies; sometimes they 
are connected with carious teeth or badly fitting artificial dentures. 
Those cases in which desquamation and a varnished appearance 
are extensively combined, or involve almost the entire tongue, are 
known under the name of red tongue, or glossitis of nervous arthritics. 
Glossitis Exfoliativa Marginata. — This peculiar affection which 
also bears the names of exfoliatio areata, or geographical tongue, 
gives rise to circinate patches, rings and other designs upon the 
tongue. The spots are composed of a white border, one or two 
millimeters wide, within which lies a desquamated surface, bright 



KERATOSIS OF MUCOUS MEMBRANES 229 

red near the margin, gradually fading away at a distance from it. 
More or less rounded at first, the spots spread rapidly and become 
confluent with their neighbors ; the resulting design may thus become 
entirely altered in a day or two. New spots are incessantly repro- 
duced. There is no induration of the mucosa. 

Entirely indolent, usually ignored by the bearer, this affection 
lasts for years or indefinitely. Its etiology is unknown. It is 
observed in children and in adults. It is often familial. Sulcated 
tongues are specially predisposed to it. In spite of the parasitical 
appearance of the lesions, no case of contagion has been reported. 
Confusion must be guarded against, especially with syphilitic lesions. 
Parrot referred exfoliative glossitis to congenital syphilis, which is 
certainly incorrect. 

[Chronic superficial excoriation of the tongue, or Mceller's glossitis, 
is characterized by irregular circumscribed intensely red spots of 
great chronicity, without tendency to extension or ulceration, located 
in the middle or the anterior portion of the tongue. Contact with 
food usually provokes severe burning or lancinating pain.] 

Black (Villous) Tongue. — This is a lingual keratosis, in which the 
filiform papillae, far from becoming obliterated, as in leukoplakia, be- 
came immediately elongated and assume a dark, black or brown color. 

The affection begins on the middle line, not far from the circum- 
vallate papillae and spreads forward and to the sides, remaining 
more pronounced at its point of origin; the borders of the lesion are 
diffuse. The papillae, which may reach the length of a centimeter, 
lie like mown wheat and a parting may be made as in the hair 
(black hairy tongue). The brown color is darker at the extremity of 
the papillae. 

When these papillae are excised, the microscope shows an enor- 
mous hypertrophy of their corneal sheath, the lamellae of which 
adhere to the axis and spread away from it like the branches of an 
old pine tree. The presence of eleidin has been reported at the 
border of the rete. The black color is due, not to foreign bodies 
or to pigment, but to a smoky tinge of the horny substance itself, 
as in black ichthyosis. 

This rather uncommon affection is observed in adults and aged 
individuals; I have seen it associated with pharyngo-mycosis . It 
proceeds in attacks, followed by partial desquamations; it is 
sometimes prolonged for months or years and has a tendency to 
recurrence. 

Black tongue is neither contagious nor inoculable. It has been 
suspected of being due to a special infection by a microbe or a yeast. 
But the results of investigations which have been undertaken to 
prove this are entirely contradictory and the parasitical theory can 
no longer be maintained (Lebar, 1917). 



230 



KERATOSES 



There arc cases of villous tongue, presenting identical features, 
but without a brown or black coloration. 

This affection must not be confused with a simple coated tongue, 
with an accidental discoloration due to articles of food or medicinal 
agents, with the pigmentation of Addison's disease or that of 
argyria. Mouth washes with peroxide water sometimes produce 
at the end of a certain time an appearance identical with that of 
villous black tongue; but the surface promptly returns to the normal 
when these washes are omitted. In several great dystrophies, such 
as acanthosis nigricans and psorospermosis, the tongue is villous 
in its entire extent, but of a normal or whitish hue. 

The treatment consists of alkaline mouth washes and painting with 
a 5 per cent, or 10 per cent, alcoholic solution of salicylic acid. 

DYSKERATOSES. 

The dermatoses which I group under this heading are charac- 
terized by a faulty development of the epidermis, in the course of 
which a certain number of Malpighian cells become differentiated 
from their fellows, undergoing an abnormal, premature and imper- 
fect keratinization. These dyskeratotic cells are present in the 
layers of the epidermis, as far as in the horny layer, in the form of 




FlG. 75. — Round bodies and granules of follicular psorospermosis. a and h 
round bodies, Malpighian cells surrounded by a membrane and containing granula- 
tions of keratohyalin and a nucleus; c and d, granules, nucleated dyskeratotic cells 
which have completed their development. 



"round bodies," "granules" (Fig. 75), globes or corpuscles, with 
or without nuclei, easily distinguished from the still normal cells as 
well as from the parakeratotic cells. 

The group of dyskeratoses comprises: (1) The disease which I 
had named psorospermosis follicularis vegetans; (2) Paget's disease 
of the nipple; (3) the precancerous dermatosis of Bowen, or lenticular 
and disco id a I dyskeratosis. 

From the strict viewpoint of the histological structure, moUuscum 
contagiosum should likewise be classified with the dyskeratoses; 



DYSKERATOSES 231 

but this affection is altogether different from the preceding and 
will be discussed with the benign tumors. 

Dyskeratosis and analogous cellular changes are also observed 
in several forms of cancer, notably in the majority of spinocellular 
epitheliomas, where they were formerly described under the name 
of physalides (Virchow) and more recently under that of pseudo- 
coccidias; and two dyskeratoses, Paget's disease and Bowen's, take 
first rank among the precancerous affections. This fact is interest- 
ing and suggestive, but its significance is not clear as long as the 
cause and nature of dyskeratosis remain unknown. 

Darier's Disease. — This important dermatosis which I described 
in 1889 under the name of psorospermosis follicular is vegetans, is gen- 
erally called Darier's disease, especially abroad; the most appropriate 
denomination for it, in my opinion, would be dyskeratosis follicularis. 1 

It manifests itself clinically as papulo-crusts, often follicular, 
capable of becoming confluent in verrucous surfaces with crumbly 
margins, located symmetrically in certain definite regions. It is 
essentially chronic and almost incurable. 

The improper name of psorospermosis which I had attributed to 
it, was based on an erroneous interpretation of the corpuscles which 
are found in the epidermis and which at the time were mistaken 
for coccidia or psorospermia, namely for parasites of the sporozoa 
group. They have now been shown to be really dyskeratotic epi- 
dermic cells. 

The etiology of this dermatosis is unknown, it has been observed 
in all countries, but is relatively rare; it seems to affect the 
male sex somewhat more frequently; its familial and hereditary 
character is apparent from numerous observations, but there is 
nothing to indicate contagiousness. It has been compared with 
ichthyosis, the icthyosiform hyperkeratoses and acanthosis nigricans; 
there is a tendency to regard it as a dystrophy of the epidermis of 
congenital origin. 

The typical eruptive lesion is a papule covered with a grayish 
brown crust, having the dimensions of a pin-head to a small lentil. 
On removal of the hard and horny, prominent or flattened, rather 
adherent crust, it is found to be imbedded in a funnel-shaped de- 
pression with raised margins, into which it sends a soft yellowish 
process, of sebaceous appearance; this depression is the dilated 
orifice of a pilo-sebaceous follicle. There are other lesions, however, 
which are not follicular. 

At the onset the patients notice a dirty tinge and roughened 
state of the skin; later on, the crusts become confluent in warty 
patches. 

1 In the original this section is headed Psorospermosis, etc. The editor has 
substituted the name by which the disease is generally known. — S. P. 



232 



KERATOSES 



In the groins, the axilla' and in all moist regions, pinkish globular 
or crater-shaped vegetations may develop, in exceptional cases, 
arranged in cauliflower or fungoid masses, having an offensive odor. 

The eruption is symmetrical and occupies large areas. Its sites 
of election are: the face, especially the temples and the naso-labial 




-Follicular dyskeratosis [Darier's disease]; gene 
dermatosis. 



distribution of the 



fold; the scalp, which becomes crusted and moth-eaten, but without 
alopecia; the concha? of the ears, the presternal and interscapular 
grooves; the belt line, the perigenital region and the large articular 
folds. This topographical distribution is in the main that of 
seborrhea (Fig. 76); tlie entire trunk and the external aspect of the 



DYSKERATOSES 



233 



limbs may be likewise involved. So-called abortive or incomplete 
cases are not very uncommon. 

On the back of the hands, elevations identical with flat warts are 
often seen; the palmar and plantar regions present a punctate 
keratosis composed of yellowish translucid points; the nails are 
striated and brittle; the tongue may be villous. 

The disease begins, in one-half of the cases, between eight and 
sixteen years of age (Fig. 77), but also earlier or later; sometimes 
at the temples and face, sometimes in the groins; it spreads rapidly 
and then remains indefinitely stationary. It is accompanied by no 
subjective symptoms and interferes in no way with the general 
health. 




Fig. 77. — Follicular dyskeratosis [Darier's disease] in a girl aged eleven years. 



The pathological anatomy is characteristic. The illustration 
(Fig. 78) conveys a sufficient idea of the condition. 

The microscopical demonstration of the granules in the crusts 
which are easily removed from the patient, and of the round bodies 
in the underlying substance, is very easy and suffices for a positive 
confirmation of the clinical diagnosis. 



2:51 KERATOSES 

Without curing the psorospermosis entirely, it is possible to 
improve the patient's condition very markedly by baths and soap 
washes, inunctions with salves containing keratolyses, followed by 
reducing agents as well as by means of radiotherapy. 

Paget's Disease of the Nipple. -This is a chronic affection which 
develops on the nipple and areola of women past forty years of age; 
or, exceptionally in men in the perineoscrotal and some other regions. 
It seemes to be less uncommon in England and in the United States 
than in France. 






/* 






. ■' V:- 






; 




. j** 



6 



Fig. 78. — Histology of follicular dyskeratosis; section through a perifollicular 
papulo-cmst. a, orifice of a hair-follicle ; b, b, hairs, and c, sebaceous gland, unchanged; 
d, thickened horny layer containing (in e e) collections of granules; /, /, granular 
layer interrupted at the level of the foci of dyskeratosis; g, g, fissures and lacunae, 
resulting from fibrino-nmcous disintegration of the epidermis, in which a few granules 
are seen Boating {h, h); i, i, round bodies. 

At the onset, only a few small crusts are seen on the nipple, 
with warty elevations and sometimes a serous oozing. After some 
months or years, a progressively extensive erosion makes its ap- 
pearance and may invade the entire integument of the breast. At 
its fully developed stage, there exists an eroded or ulcerated red 
patch, mottled with pinkish epidermis-covered islands, remarkable 
for its distinctly outlined polycyclic contours, which are bordered 
by a narrow margin or cuff of scales (Fig. 79). The eroded surface 



DYSKERATOSES 235 

presents a very distinct parchment-like induration; it never under- 
goes retrogression or spontaneous cure. The nipple is retracted. 
The lymph glands are not usually enlarged. Finally, sometimes 
after a considerable number of years, a malignant neoplasm may 
supervene in the form of a hard superficial or deep node which ulcer- 
ates and presents the usual appearance of cancer of the lactiferous 
ducts, or of ordinary cancer of the breast. 

The differential diag?wsis from eczema of the mammary areola, 
which is practically limited to the puerperium or to cases of scabies 
(Fig. 157), has less distinctly circumscribed borders and takes an 
acute course, is easy. Certain superficial epitheliomas, which simu- 
late Paget's disease, can be differentiated only by means of biopsy. 




Fig. 79. — Paget's disease of the nipple. After a cast in the Museum of the St. Louis 
Hospital, Paris. 

The histology of Paget's disease shows a Malpighian layer inter- 
spersed or even packed with vacuolated cells and round bodies, 
as well as cells with deformed, sometimes monstrous nuclei; their 
large numbers as well as the acantholysis of the intermediate 
cells, gives the epidermis a disorganized appearance and leads to 
the production of oozing or crusted erosions. The scales which 
persist, appear under the microscope dotted with vacuoles and 
pseudococcidia. The papillary body is infiltrated with plasmocytes, 
sometimes arranged in a continuous layer. 

The threatened contingency of cancer necessitates the treatment 



230 KERATOSES 

of Paget's disease by [radical] surgical measures. Radiotherapy lias 
been tried, without success. 

Precancerous Dermatosis of Bowen or Dyskeratosis Lenticularis 
et Discoides. —I have recommended that the name of J. T. Bowen 
be attached to an essentially chronic and progressive derma- 
t * » — i — first described by him in 1912. It appears in the form of 
lenticular or nummular disks (Fig. ml. later patches of irregular 
shape, covered with thick scaly crusts; the lesions are generally 
multiple, non-symmetrical, and may be situated anywhere. Atro- 
phic spots, resembling Paget - - disease, may also be seen. 




Fig. 80. -Dyskeratosis <>f Bowen. showing a patch composed of lenticular and dis- 
coid lesions on the internal malleolus of a woman, aged thirty-nine years. Personal 
observation, 1914. 

The histological structure of the lesion is entirely analogous with 
that of Paget's disease, especially in regard to the dyskeratosis and 
the vacuolization; but in Bowen's disease a well-marked hyper- 
keratosis is demonstrable. The differential diagnosis from psoriati- 
form eczematides, tertiary syphilides, psoriasis, senile keratosis 
Lupus erythematodes, certain forms of lichen, etc., must be con- 
fin mi 1 by biopsy. 

In one-half of the reported cases, the affection was observed to 
degenerate into cancer. Hence, there is good reason for expressly 
recommending the total destruction, or better, the surgical removal 
of the diseased areas. 



CHAPTER XII. 
PAPILLOMATOUS AND PROLIFERATING DERMATOSES. 1 

Papillary proliferations are more or less prominent excres- 
cences, which may be conical, filiform, or resembling a cauliflower 
growth, arranged in patches or spread out over large areas. 

They must not be interpreted as resulting simply from the 
elongation of preexisting normal papilke; on a given surface the 
normal papillae are actually infinitely more numerous than the 
excrescences which can lodge there. Each proliferation really 
corresponds to several papilla?, united on the same axis or connective 
tissue vascular stalk. 

The anatomical conditions which give rise to the phenomenon 
of papillary proliferation can be explained in three different ways: 
It may result from an active primary proliferation of the upper 
layer of the derma known as the papillary body, or from a primary 
proliferation of the rete Malpighii; or from a simultaneous hyper- 
trophy of these two layers. As a general rule, as was demonstrated 
by Auspitz, the Malpighian hyperplasia, known as acanthosis or 
hyperacanthosis, is the original disturbance. It is not understood 
why this gives rise sometimes to a simple epidermic papule (for 
instance, the flat juvenile wart), sometimes to a papillomatous 
elevation (for instance, the papillary wart). 

The horny layer which covers the proliferations may have its 
normal thickness, or it may be thinned, as in the venereal warts; 
or on the contrary, thickened as in common warts. Hence, there 
are naked proliferations with a smooth pink surface; others have 
the normal color of the skin; still others are of a grayish yellow color, 
firm consistence, and evidently hyperkeratotic. The latter are 
named verrucosities or verrucous excrescences. 

No very distinct boundary line can accordingly be established 
between the two dermatological forms of keratoses and verrucosities. 

As regards the term papilloma, this approximately corresponds to 

1 In the original, this chapter is headed vegetations et dermatoses vegetantes. 
These terms cannot be literally transcribed into English. The term vegetation con- 
notes a papillary proliferation for which the word papilloma was formerly used. But 
as Virchow long ago pointed out, this term is unscientific; the condition is not a 
tumor of the papillary body but rather a proliferation of the interpapiliary epithelial 
processes with secondary changes in the papillae. The adjective papillomatous, 
however, may properly be used to indicate this clinical condition. — Ed. 



238 PAPILLOMATOUS AND PROLIFERATING DERMATOSES 

that of vegetation, and like the latter does not designate a dermato- 
logical type or species, but an objective appearance which may be 
brought about in a variety of dermatoses and tumors. 

Papillomatous Dermatoses. — These can be divided into three 
groups : 

A. Essential Papillomatous Dermatoses. — Some are circumscribed, 
like the venereal warts, which will be discussed in a special para- 
graph; the same is true for common wafts. 

The verrucous nevi have been mentioned in connection with the 
circumscribed keratoses and will figure again among the nevi in 
general (XXXI). 

Others are generalized or regionally diffused. It is sufficient to 
recall the hystrix varieties of ichthyosis and generalized hyper- 
keratosis. Under this heading belongs a peculiar cutaneous dys- 
trophy, known as acanthosis nigricans. 

B. Accidentally Papillomatous Dermatoses. — Several skin diseases, 
of infectious, toxic, or indefinite character, may present proliferations 
as a form of eruption, as an accidental manifestation, or as a develop- 
mental phase. From the diagnostic point of view, it is important 
to compare them with each other. 

C. Tropical Proliferating Dermatoses. — The establishment of this 
group may appear unscientific; but it is justified in the present 
state of our knowledge and, moreover, is convenient. 

VENEREAL WARTS. 

Also named condyloma acuminatum and popularly known [in 
France] as cauliflower growths, cock's comb, etc., venereal warts 
are agminated papilliform excrescences, of a pinkish or grayish 
color, having their seat of predilection about the genital organs and 
the neighboring folds. 

In men, they are almost exclusively situated in the glando- 
preputial groove, on the corona glandis and the frenum, but may 
affect the entire prepuce and the urethral orifice. 

In women (Fig. SI) they affect the vestibule of the vulva, the 
fourchette, the preputium clitoridis and sometimes cover the entire 
vulva, the genito-crural folds, the anus and the intergluteal region. 

At the onset, the lesions are simple pinkish granules or branching 
elevations, like a mole's paw; as they grow they form tufts of fili- 
form or lamellar processes, sometimes reaching a length of several 
centimeters. Whether sessile or pedunculated, the warts originate 
on a healthy unthickened skin or mucosa, which is sometimes irri- 
tated or macerated. In women who are neglectful of cleanliness, 
especially in case of gonorrhea and pregnancy, they finally form 
enormous mammillated masses the size of a fist, bright red in color, 



VENEREAL WARTS 



239 



oozing and offensive. They cause inconvenience but no actual pain. 
They may be found very rarely in the axillae and on the scalp, but 
not elsewhere. 

The histology of these growths shows a very pronounced hyper- 
acanthosis, with abundant karyokineses, covering filiform and 
branched connective-tissue protuberances which are traversed by 
bloodvessels with large lumina. There may be no suggestion of 
acute inflammation in these tissues. The granular layer is dis- 
continuous, the horny layer is very thin. 




Fig. 81. — Venereal warts of the vulva. 



The etiology has not been elucidated; these growths are reputed 
to be contagious and auto-inoculable; on the other hand, I have 
certainly known them to appear without direct contagion, under 
the influence of ordinary irritations, gonorrhea, pregnancy, etc. 
Their kinship to common warts has been frequently suspected, but 
has not been demonstrated. 

Treatment by attention to hygiene, astringent lotions, bland 
powders, pulv. Sabinse with an addition of salicylic acid, 2 per cent, 
will usually cause them to wither, though not to disappear entirely. 
Among caustic agents, pure carbolic acid, or chromic acid, may 
prove successful when the warts are very small. 

Voluminous growths require ablation with the scissors, or detach- 
ment with the forceps, or better with a curette; the operation is 
rather painful. Anesthesia, local or general, is sometimes necessary; 



240 PAPILLOMATOUS AXD PROLIFERATING DERMATOSES 

inferior spinal analgesia with cocain, which deprives the region of 
all sensation, would be very valuable in extreme eases of profuse 
and exuberant growth. My assistant and friend Dr. Chicotot has 
successfully removed large masses of condylomata by means of 
radiotherapy. 

VERRUCA VULGARIS. 

A common wart is a papillary hyperkeratotic excrescence; it is 
typical of products of this sort, which are accordingly known as 
wartv or verrucous. 




Fig. s2. — ( iomrnon wails on the hands of a school-boy. Note near the left thumb 
a trail of four waits which developed on a scratch made with a pin. 



A w;irt consists of a rather prominent, rounded and distinctly 
circumscribed elevation, from the size of a pin-head to that of a 
small bean, usually as large as a pea, of a grayish, yellowish or gray 
black color, with a mammillated surface sometimes studded with 
villous protuberances, of a hard rough consistence. The surround- 
ing skin is not congested. Some warts are constricted at their base, 
almost pedunculated, while others spread out and are not much 
raised. They are not sensitive or painful except at the borders of 



VERRUCA VULGARIS 



241 



the finger-nails and in regions exposed to pressure, notably on the 
soles of the feet. 

Warts are usually multiple and have their seat of election on the 
dorsal or lateral aspects of the fingers and the hand (Fig. 82), where 
they may become confluent in patches, they also occupy the peri- 
ungual or subungual groove; more rarely; the palm of the hand or 
fingers, the face, the eye-lids, the scalp and the soles. 

Juvenile flat warts are probably only a special form of the same 
affection (p. 130). 




Fig. 83. — Plantar warts in a girl aged twenty yeai 



Plantar warts, described by Dubreuilh and M. Robert, are 
noteworthy on account of their extreme tenderness and the special 
treatment which they require. They are preferably situated on 
the supporting points of the foot and at first sight resemble calluses, 
but on closer examination, they are seen to be usually composed 
of filiform growths, arranged in a cluster and surrounded by a raised 
border (Fig. 83). They can be cured without much difficulty by 
means of radiotherapy. [I have encountered some plantar warts 
which are extremely resistant to treatment and have yielded only 
to the actual cautery or to applications of carbonic acid snow after 
the removal of the thick horny layer by means of strong salicylic 
acid plasters and curettage.] 

All warts may become fissured and inflamed. 
16 



242 PAPILLOMATOUS AND PROLIFERATING DERMATOSES 

These formations are extremely common and are observed espe- 
cially in schoolboys, in youthful individuals doing manual labor, 
but also in adults. The contagiousness and auto-inoculability 
of warts, always asserted by the laity, have been proved beyond 
a doubt by the experiments of Variot and others; the incubation 
lasts longer than a fortnight. The microbe is unknown; the bacillus 
porri which has been described, has not been proved to be the 
causative agent. [Wile and Kingery have reproduced epithelial 
hyperplasia by injection of the filtrate made from the substance of 
common warts.] 

The histology of Avarts shows an enormous increase in the length 
of single papillae or of groups of papilla? and of their vessels and a 
considerable thickening of all the layers of the epidermis; there is 
no inflammatory infiltration in the cutis. 

The treatment must aim at the avoidance of cicatrices, for 
the warts often disappear spontaneously. It is most advisable to 
cauterize them carefully with the galvanocautery, or with a very 
fine point of thermocautery, assisted by the curette. Carbonic 
acid snow, properly applied, is likewise very successful. Radio- 
therapy gives remarkable results, without pain; but it requires 
great caution, especially on the back of the hand. 

Electrolysis has been recommended in case of large warts and 
magnesium ionization when they are very numerous; and, very 
recently, solar light condensed by means of a large lens. It is 
difficult to determine the efficacy of the daily administration of 75 
centigrams of magnesium, or of a few r drops of tincture of thuja, 
or of arsenical medication. 

Nitric acid does not deserve the favor which it enjoys, for it has 
caused innumerable burns and distressing scars. Less powerful 
caustic agents, collodium, plasters, etc., are apt to be disappointing. 
The juice of the milk-wort and of the celandine, very persistently 
applied, causes the warts to wither and drop off. 

These various measures may prove successful, but it is important 
to keep in mind a surprising but undeniable fact, stated by many 
writers, namely, that simple suggestion may have the same effect. 

[After persisting for a variable period, months or years, warts 
generally disappear without any known reason.] 

PAPILLARY AND PIGMENTARY DYSTROPHY OR ACANTHOSIS 
NIGRICANS. 

This disease was described under the latter name by Pollitzer 
and Janovski, in 1890, after I had observed and named it papillary 
and pigmentary dystrophy [but had not published the observation]. 
It is characterized by two fundamental phenomena: (1) a roughened 
condition of the skin, with scattered or agminated papillomatous 



PAPILLARY AND PIGMENTARY DYSTROPHY 



243 



elevations; and (2) a dark pigmentation. The lesions are essentially 
regional, ordinarily symmetrical, with somewhat diffuse borders. 
In order of frequency, they affect the axillae, the neck and nape of 
the neck, the ano-genital region, the internal aspect of the thighs, 
the fold of the elbow, the popliteal space, the umbilicus, the back 
of the hands, the areola of the breasts and the feet. 

The roughened condition of the integument is due to an exaggera- 
tion of the folds and fissures and does not disappear on stretching 
the skin; from this surface, which is studded with papillary pro- 
tuberances, of a brown or even black color comparable to the bark 
of a tree, but supple and sometimes scaly, arise sessile or peduncu- 




Fig. 84. — Acanthosis nigricans, of five months' standing; portion of the supra- 
clavicular fossa of a man aged forty-two years, suffering from cancer of the liver. 
After a cast by Baretta. 



lated papillomatous proliferations (Fig. 84), isolated or in patches; 
on the free border of the eyelids and lips, they may present a regular 
arrangement like the teeth of a comb. 

In the palmar and plantar regions, the normal papillary ridges are 
notably exaggerated. The tongue is nearly always villous, but the 
mucosae are never pigmented. 

The finger nails are brittle, generalized alopecia is common; 
pruritus has occasionally been noted. 

Acanthosis nigricans is a rare disease, about sixty [at least eighty 
to a hundred] observations have been reported from all countries, 
with a slight predominance of the female sex. Its principal interest is 



244 PAPILLOMATOUS AND PROLIFERATING DERMATOSES 

due to the fact that very frequently, in about two-thirds of the cases, 
it. is associated, as was first pointed out by me, with a cancer of the 
abdominal cavity, primary carcinoma of the stomach or intestines, 
for instance, or it may be secondary to a cancer of the uterus, or the 
breast, etc. This dermatosis may accordingly put the physician on 
the track of a latent cancer, as has happened in several instances. 

It begins with a dirty-looking pigmentation of the neck and axilla?, 
or the appearance of one or several warty growths. The course 
is rapidly progressive, sometimes interrupted by remissions, and 
cachexia supervenes in less than a year, two years at most. 

This so-called grave form, which occurs after the age of thirty 
years, may be contrasted with a juvenile or benign form, developing 
in children, not related to cancer and only half as frequent. The 
symptoms are usually not so marked and are more stationary; the 
duration is indefinite, but the general health is not affected. The 
pathogenesis is unknown. 

The atypical forms which have been described, can be admitted 
only conditionally and may possibly be referred to ichthyosiform 
hyperkeratosis or analogous conditions. 

Accidentally Proliferating Dermatoses. — Proliferating lesions may 
occur in a large number of acute or chronic, generalized or localized 
cutaneous affections of very variable character. The territory, or 
the affected tegumentary region is sometimes responsible. It is 
obvious, although this fact seems to have escaped the attention 
of most writers, that the peri-anal, peri-genital, inguinal, axillary 
regions, in short the large folds, and on the other hand the borders 
of the orifices of the face, the scalp and to a less degree the extremi- 
ties are especially subject to the occurrence of papillary prolifera- 
tions. It is also possible that certain infectious agents have a 
tendency to excite proliferation; several pathogenic protozoa 
apparently possess this property. 

The assumption is, moreover, justified that the papillomatous 
character which various eruptions may accidentally develop, is 
referable to a secondary infection or a microbic symbiosis. 

Pemphigus Vegetans Gravis. — This pathological type was described 
in L876 by J. Neumann, who considered it as a distinct disease. It 
is characterized by bulla' on the Moor of which papillomatous 
growths very promptly make their appearance. The eruption is 
situated especially in the groins, in the large articular folds and at 
the circumference of the mouth. It often begins on the buccal or 
pharyngeal mucosa, or at the genital organs; sometimes at the 
border of the finger-nails [or at the anus]., 

The initial lesion is a bulla, often flaccid and seropurulent from 
the first, which dries into a crust and may heal locally or spread 
at the periphery. At the end of five or six days, the floor of some 



PAPILLARY AND PIGMENTARY DYSTROPHY 245 

or most of the bullae becomes excoriated, begins to proliferate, 
undergoes a papillomatous change and secretes an offensive pus 
under a brownish crust. There is a striking resemblance between 
these lesions and hypertrophic mucous patches. Serpiginous 
extension and confluence of the lesions give rise to extensive sur- 
faces, mammillated in the center and pustular at the circumference. 
Healing is followed by brownish and roughened macula?. 

In severe cases, the mouth is lined with very painful diphtheritic 
erosions, the lips, all the articular folds and the regions where skin 
rests upon skin, sometimes a considerable portion of the head, 
trunk and limbs, as well as the mucous membranes, are covered 
with fetid and painful suppurating vegetating ulcerations. Fever 
has been repeatedly noted. Death supervenes from cachexia in 
two to six months, sometimes later. 

The histology of the initial bulla is that of genuine pemphigus. In 
the papillomatous stage, the excrescences, which may reach a height 
of 6 to 10 millimeters, are covered with a greatly thickened rete 
Malpighii. In the latter, or in the proliferating papillary body, or 
between these two tissues, small abscesses are demonstrable, with 
polynuclear leukocytes and numerous eosinophile cells. Fosino- 
philia have been demonstrated in the blood and various lesions of 
the nervous system and the viscera have been found at autopsies. 
Pemphigus vegetans gravis is observed in both sexes, especially in 
adults, but it is a rare disease. Its nature is unknown. Its unfav- 
orable course and gloomy prognosis suggest that it is merely a 
variety of genuine pemphigus, which has become papillomatous 
through a superadded infection with an undetermined agent. G. 
Pernet (1907) is undoubtedly right in claiming that pemphigus 
vegetans is not a definite pathological variety, but is referable to a 
number of infectious agents among which he states the Bacillus 
pyocyaneus to be especially common. [The pyocyaneus, however, 
is extremely common everywhere!] 

Pemphigus Vegetans Benignus. — Beside the above described almost 
invariably fatal form, an eruption is sometimes observed having 
very similar lesions, but advancing in successive attacks, with 
preservation of a good general condition and terminating in recovery 
after a variable length of time. In this benign form, the mouth, 
lips and large folds are not so much involved ; whereas the skin of the 
extremities and the large surfaces of the trunk (Fig. 85) suffers more. 

There is a striking similarity with bromoderma and iododerma 
vegetans. 

The coexistence of polymorphous eruptive lesions and eosinophilia 
of the blood has often been interpreted as pointing to a prolifera- 
tive form of Duhring's disease. Non-recurrent cases have on the 
other hand suggested the idea of erythema bullosum vegetans. 



240 PAPILLOMATOUS AND PROLIFERATING DERMATOSES 

On the whole, the scries of forms of pemphigus vegetans presents 
the same difficulties of classification as the bullous eruptions in 
general. Some dermatologists simplify the problem by recognizing 
a dermatitis vegetans capable of assuming every imaginable degree. 

Treatment. The treatment is that of infected erosions of all 
kinds: prolonged local baths, softening or mildly antiseptic moist 
dressings, with hypochlorites, permanganate, etc., painting with 
iodin solution, application ^of absorbent powders. Arsenic and 
especially arsenobenzol have yielded some very satisfactory results. 
Radiotherapy is likewise successful. 




Fig. 85. — Benign pemphigus vegetans; patch of five months' standing in a 
child aged five years; blood withdrawn from the lesions contained 30 per cent. 6f 
eo M,. iphiles. 



Proliferating Pyodermatitides. — Under the name of chronic pustular 
dermatitis in feci with peripheral extension, later as pyodermatitis 
vegetans, Hallopeau I L889 ISDN) described a form which is pustular 
from the onset, benign in character, slowly progressive and very 
protracted, as a variety of Neumann's pemphigus vegetans. 

The name of pyodermatitis vegetans might also be applied to the 
cases in which an impetigo or an infected herpes, etc., give rise to 
papillomatous proliferations, which is especially apt to occur in 
the folds. (Sec Syphiloid Dermatitis Vegetans.) 

Papillomatous and Verrucous Elephantiasis.- — In all forms of 
elephantiasis, especially in elephantiasis nostras and still more in 
the secondary elephantiases, the cutaneous surface, chiefly on 
the lower part of the legs and on the feet, may become roughened, 



PLATE I 




Vegetative Syphilides of the Secondary Stage. 

The patient presented at the same time vegetative mucous patches upon 
the lips and under the tongue. 



PAPILLARY AND PIGMENTARY DYSTROPHY 247 

mammillated, covered with pink or whitish proliferations, or with 
gray or blackish hyperkeratotic verrucosities. 

Hypertrophic Lichen Corneus. — This affection, which is very 
easily recognized after seeing a case, has been described above 
(p. 140). 

Papillomatous Syphilides. — These are either secondary or tertiary. 
The secondary kind constitute a modification of the lenticular or 
especially the nummular papules. Generally isolated or not 
numerous, they occupy the nape of the neck (Plate I), the thorax 
or the face and assume the shape of distinctly circumscribed, 
sometimes crusted papillomatous patches, 0.5 cm. thick, from 1 to 
4 cm. wide, developing gradually and leaving a dyschromic spot. 
They are not rare in the nasogenial furrow and at the fold of the 
chin. 

Hypertrophic mucous patches belong entirely under this heading. 
The syphilitic patches of Legendre are related lesions. 

Tertiary proliferating syphilides may develop on a variety of 
ulcerations, especially on tuberculo-gummous syphilides. In these 
cases, papillomatous or fungoid papillomatous growths are seen 
arising from the depths of solutions of continuity, radically altering 
the appearance of the lesions. This contingency must be kept 
in mind, for tertiary proliferating syphilides are often confused 
especially with epitheliomas. They are observed more particularly 
in hairy regions, the scalp, beard, axilla, pubis and on the lower 
limbs; they may accompany an elephantiatic state. 

Papillomatous and Verrucous Tuberculosis. — The cutaneous tuber- 
culous lesions are proliferative under various conditions. Irregular 
patches of ulcerative papillomatous tuberculosis may be observed, 
although not commonly, either at the circumference of the mouth 
or at the anus, or finally at the vulva, where they are sometimes 
considered as part of the syndrome of vaginal lupus. Pinkish or 
papillomatous proliferations arise from the floor or the border of 
the ulceration. The course is extremely slow. 

From time to time, cases of frambesif orm tuberculosis are reported, 
representing large surfaces covered with villous proliferations and 
interspersed with irregular ulcers and miliary abscesses. A lesion 
of this kind, which covered almost the entire extent of the thigh 
and buttock was observed by myself and Brocq. 

Tuberculosis Verrucosa. — Tuberculosis verrucosa is more common, 
and is entitled to a detailed description. It is usually found on 
the hand, on the fingers or on the wrists; it has a certain predilec- 
tion for the radial side of the hand and especially for the thumb 
(Fig. 86) ; but it is also met with on the elbows, the knees, in the 
peri-anal region, on the buttocks, the feet, the neck and even on- 
the face. It appears in the form of a single patch, of nummular 



248 PAPILLOMATOUS AND PROLIFERATING DERMATOSES 

dimensions or more extensive, of a round, oval or multilobular 
configuration, sometimes elongated, following a fold of the skin. 

When the focus is small, it is a papillomatous or hyperkeratotic 
elevation, somewhat resembling- a wart; but its base is always 
surrounded by a red or purplish areola; pressure will occasionally 
cause a small drop of pus to escape. 

In its completely developed state, a patch of verrucous tuber- 
culosis is composed of three zones: at the circumference, a smooth 
and level erythematous zone; next, a more elevated, purplish or 
brownish, papillomatous median zone, interspersed with small 
adherent crusts or cribriform ulcers, from which droplets of pus 
can be squeezed out; finally, a central portion, which is sometimes 
cicatricial and depressed, sometimes protuberant and studded with 
gray or yellowish horny verrucosities, separated by grooves and 
fissures. The base of the patch is indurated, of fibrous rather than 
edematous consistence. 




Fig. 86. — Tuberculosis verrucosa. After a cast of Baretta's in the Museum of the 
St. Louis Hospital. 

After healing has occurred, the cicatrix is flat and white, or 
undulating and interspersed with light tracts on a purplish back- 
ground. It is adherent when the cutaneous lesion was derived 
from a deep, bony, or glandular focus, etc. 

The diagnosis of tuberculosis verrucosa, based on its objective 
features, its seat, the conditions under which it appears, and its 
slow course, is usually easy. Examination by biopsy, bacteriolog- 
ical examination and experimental inoculation will serve to confirm 
it in those cases where syphilis, epithelioma, sporotrichosis, the 
blastomycoses, etc., cannot be readily excluded. 

Anatomical tubercles may be regarded as a verrucous tubercu- 
losis, of small dimensions, but highly virulent. 

Discussion of the etiology and treatment of these affections will 
be found elsewhere in this book (p. 552). 



PROLIFERATING TROPICAL DERMATOSES 249 

Proliferating or Papillomatous Epithelioma. — This is observed 
chiefly in the face, especially on the lips or on the mouth and also 
on the external genital organs. 

This papillomatous epithelioma often develops on a basis of 
senile keratosis or leukoplakia. Surgical excision, as promptly as 
possible, is indicated. 

Mycoses, Sporotrichoses, Etc. — An appearance identical with or 
closely analogous to that of papillomatous syphilides, papillomatous 
epithelioma, and especially tuberculosis verrucosa, may be pro- 
duced by a blastomycotic or sporotrichetic infection. At the 
present day, when the frequency of the mycotic dermatoses has 
been established, especially through the work of de Beurmann and 
Gougerot, it would be a serious error not to take this possibility 
into consideration, whenever it is plausible. The investigations 
required for its verification will be discussed elsewhere. 

Papillomatous Toxicodermas. — Iododerma papillomatosum may 
appear in any region of the integument, beginning as a purulent 
bulla with an inflammatory base, which becomes papillomatous at 
the center and rapidly extends peripherally. The usually multiple 
lesions become confluent in sometimes rather extensive patches; 
their pustular margin is suggestive. 

Bromoderma papillomatosum greatly resembles the iodide erup- 
tion, but is softer, more fungoid, with less tendency to suppurate. 

In both cases, in the absence of definite information, iodin or 
bromin may be looked for in the urine. It is noteworthy, however, 
that these eruptions may persist several weeks after the last inges- 
tion of the drug. [In the case of nursing infants the eruption may 
develop in consequence of a bromide or iodide mixture taken by 
the nurse.] 

PROLIFERATING TROPICAL DERMATOSES. 

A group of diseases endemic in tropical countries is characterized 
by proliferating or ulcero-vegetative eruptions. 

Their objective appearance is sometimes typical, but they are 
nevertheless apt to be confused, especially with tuberculosis and 
syphilis. In a general way, it may be stated that tuberculosis 
verrucosa differs by its slow course and the small number of foci 
which never heal spontaneously; and syphilis, by its polymorphous, 
protean manifestations, which do not spare the mucosae and which 
follow a definite course. 

In most cases, a valuable diagnostic indication is furnished by 
the mode of origin, the disease appearing either in the country 
where it prevails, or in returning travellers. 



250 PAPILLOMATOUS AXD PROLIFERATING DERMATOSES 

Oriental Boil (Biskra Button). — In its developed stage, the Biskra 
button (p. 648) is a round or oval ulceration, the size of a small 
coin or several centimeters in diameter, with festooned outlines, 
concealed under a very adherent yellow-brown crust and bordered 
by an erythematous margin (Fig. 186). 

Under the crust is found a turbid serous fluid, an ulcer with 
perpendicular eroded ragged margins and a bright-red, granular, 
mannnillated and papillomatous floor. On this floor and around 
the circumference, purulent yellow points may be found. The 
base is congested and infiltrated. Lymphangitis and phlebitis are 
frequent complications. The glands are as a rule enlarged and 
painful. 

Spontaneous cicatrization is slow, requiring several months. 
The scar which persists is depressed, smooth, colorless or of a dusky 
red hue, with peripheral pigmentation. 

The histological structure is that of a granuloma, with predomi- 
nance of mononuclears, a few plasmoeytes and foci of necrosis. 
The papillary hypertrophy is considerable, with hyperacanthosis 
and parakeratosis. 

Yaws. — The eruptive lesion in yaws or Frambesia tropica, in the 
primary lesion as well as in the generalized eruption, always consists 
at the onset of a rose-red conical elevation, with a crusted necrotic 
center; the crust is discharged, the lesion extends and becomes 
papillomatous (p. 646). 

The patches may attain a diameter of 1 to 6 cm.; they are covered 
with an adherent brown crust, or a fetid secretion in the macerated 
areas. The proliferations are grayish or pinkish ; there is no ulcera- 
tion or loss of substance. The center has a tendency to collapse; 
the circumference is often the seat of a bullous elevation. Con- 
fluence gives rise to the formation of large patches with polycyclic 
outlines. The eruption is usually painless. 

A spontaneous cure may occur at any stage of development; it 
manifests itself by the lesions becoming flattened and undergoing 
absorption. Only pigmented macules are left behind, and, as a 
rule, no cicatrices. 

The site of election of the eruptions in yaws is around the natural 
orifices, at the lips, the nostrils, in the genital regions and in all 
body folds. But they may be very extensive and profuse, suggest- 
ing hypertrophic mucous patches and papulo-crusted syphilides. 
In the palmar and plantar regions, the proliferations are covered 
with hyperkeratoses and are very painful. The mucous mem- 
branes always remain free. 

Histology shows an abundant infiltration of plasmoeytes, without 
epithelioid cells or giant cells; it occupies the papillary body and 
the papilla-; the latter are enormously hypertrophied and traversed 



PROLIFERATING TROPICAL DERMATOSES 251 

by dilated vessels. Hyperkeratosis is considerable and parakeratosis 
is common. 

Elsewhere mention will be made of the proliferative papilloma- 
tous ulcers of Boubas, which are accompanied by similar lesions of 
the mucous membranes (p. 650). 

Ulcerating Granuloma of the Genital Organs (Granuloma 
Inguinale, Granuloma Venereo, Groin Ulceration). — This is a chronic 
and contagious, ulcerative or papillomatous dermatosis, venereal 
in most cases, occurring in all countries, notably in South America, 
especially in Guiana and Brazil, as well as in New Zealand and 
the East Indies; a few cases have been reported in England. It 
attacks adults of both sexes and all races. 

Beginning with a nodule on the genital organs, it spreads in the 
form of an ulcerative granular patch to the groins, the pubis, the 
perineum and invades the mucosae. The borders are distinctly 
marked; the surface is riddled with papillomatous elevations, super- 
ficially ulcerated, of a bright red color; it secretes an offensive serous 
fluid; the center becomes cicatricial. This lesion lasts many years, 
without causing glandular enlargement or giving rise to cachexia. 

Histologically, it is a plasmoma with enormous hypertrophy of 
the papillae, analogous to yaws. According to a very recent and 
excellent contribution by Souza Araujo (Rio de Janeiro, 1917), the 
causative agent seems to be the germ discovered by Donovan in 
1905, which has since been isolated and cultured and is known as 
Calymmato-bacterium grannlomatis. This encapsulated bacillus is 
Gram-negative, takes the Giemsa stain and is abundantly present 
in the cells of the granuloma and in the secretion. The specific 
treatment of the disease consists of intravenous injections of 
tartar emetic. 



CHAPTER XIII. 

TUBERCLES AND TUBERCULO-ULCERATIVE 

DERMATOSES. 

In the dermatological [as distinguished from the pathological] 
sense of the word, tubercles are pathological products of the cutis, 
solid (that is, without fluid contents), circumscribed, rounded, more 
or less prominent, of slow development, deep and especially damag- 
ing to the cutis. 

This last named and most essential characteristic involves a 
frequent tendency of tubercles to ulcerate and almost always to 
leave a cicatrix in their place, with or without previous ulceration. 
This fact is expressed in the statement that tubercles do not undergo 
resolution. 

The differentiation of tubercular eruptions from papules, nodules 
and tumors, must first be clearly understood. Papules are dis- 
tinguished from tubercles, not so much by their size and prominence, 
as by their more rapid development and tendency to absorption, a 
papule leaving no scar behind it after it has healed. Doubtful or 
intermediate lesions are met with, however, which may be named 
papulo-tubercles; some dermatologists use this term for giant papules. 

Nodes and nodules are hypodermic newformations, whereas 
tubercles are dermic. But, although morphologically distinct, 
tubercles and nodules often result from the same process, justifying 
the terminology of Besnier, who defines nodules as hypodermic 
tubercles. 

Certain tubercles simulate tumors, or approximate these by their 
size, prominence, confluence in raised and mammillated patches, 
course, etc. Tubercles, however, after a more or less prolonged 
duration, have a tendency to become replaced by a cicatrix; tumors, 
on the contrary, are persistent or indefinitely progressive, although 
these features are not invariable. 

In reality the basis of differentiation is that the name of tumors 
is given to newgrowths of entirely unknown character, while 
dermic neoplasms of a known chronic infectious origin are known 
as tubercles. 

The histological criterion is decisive in this connection. As will 
be seen further on (Chapter XXXI), tumors are composed of 
heterotopic tissues which replace the normal tissue of the affected 



TUBERCULO-ULCERATIVE DERMATOSES 253 

region. Tubercles, on the contrary, are formed" by collections of 
inflammatory cells of various types, more or less coherent and 
extensive, infiltrating the strands of the derma which may have 
undergone degenerative changes. 

The abundance and density of these cellular infiltrations and 
the degree of preservation of the dermic stroma are variable and 
account for the more or less marked prominence, firmness or soft- 
ness of the tubercles. Their constitution also serves to explain 
their capacity of undergoing absorption, although usually not 
without atrophy and sclerosis, that is, not without a cicatrix. 

In some tubercles, the infiltration has a marked tendency to 
cellular necrosis, disintegration and dissolution naturally following; 
the outcome is a limited and often very deep ulceration. 

The differential diagnosis between a tuberculo-ulcerative process 
and primary ulcerations rests on its at first neoplastic and second- 
arily destructive course; furthermore, on the usual persistence of 
tubercular remnants at the base and in the circumference of the 
ulcer, indicated by a special hardness in the case of tertiary 
syphilides or actinomycosis, by a peculiar softness in the case of 
ulcerative lupus, etc. 

Indurated follicular pathological products, whether suppurative 
like furunculosis and carbuncle, or dry like keloid acne, do not figure 
in this book among the tubercles, but in the chapter on the folli- 
culoses (Chapter XIX). 

TUBERCULO-ULCERATIVE DERMATOSES. 

The presence of true tubercles or of a tuberculo-ulcerative lesion 
having been recognized, it is necessary to think in the first place of 
the great chronic infectious diseases, i. e., syphilis, tuberculosis 
and leprosy; secondarily, of the more uncommon mycotic infections, 
such as sporotrichosis, the blastomycoses and actinomycosis, for 
which the reader is referred to another chapter (XXVIII) ; finally, 
there is a group of dermatoses manifesting itself by non-ulcerative 
tubercles, the lupoid and analogous cutaneous sarcoids, which are 
undoubtedly of infectious character and probably belong to the 
tuberculides, although this has not been positively established. 

Only the following types will be described in this connection: 
(1) The tubercular syphilides, (2) the tubercles of lupus, (3) the 
tubercles of leprosy, (4) the cutaneous sarcoids or lupoids and granu- 
loma annulare. 

Tubercular Syphilides. — From the purely morphological view- 
point, leaving the course entirely out of consideration, the initial 
symptom of syphilis, the hard chancre, might be said to present 
the chief attributes of a tubercle. 



2.14 TUBERt 'LES AND TUBERCULO-ULCERATIVE DERMATOSES 

Genuine tubercular syphilides, however, are symptoms of the 
tertiary stage. 

The syphilitic tubercle constitutes the typical form of a tubercle. 
It is a dry elevation, brownish or grayish red in color, the average 
size of a lentil, projecting from 1 to 5 mm., with rounded contours, 
very hard on palpation, entirely painless. On vitropressure (mean- 
ing when the tubercle is com prosed under a glass slide), it is seen 
to be opaque and frequently pigmented. 

The subjoined illustration (Fig. 87) conveys an idea of its histo- 
logical structure. 




Fig. 87. -Histologyof syphilitic tubercle. Tuberculo-squamous tertiary syphilis. 

The infiltrate (i, i) is discontinuous, composed of lymphoid cells and plas- 
mocytes without gianl cells or epithelioid •■ell-: it forms cuffs which surround ihe 
ramifications of the bloodvessels; these are for the most pari dilated, inflamed, or 
sclerotic Between the infiltrates the dermic tissue (d) is thickened, fibrous and 
sclerotic, which explains the hardness of the lesion. The horny epidermis (c) is greatly 
thickened and coherent; at (s) it is split and shows a tendency to desquamation. 
The Malpighian layer and the papillae are preserved, excepl at (u), where the inflam- 
mation is more active and ulceration is under way. See Pathological Anatomy of 
the Syphilides, p. 628. X 20. 



A tubercular syphilitic begins as a single lesion or as a small 
coherent group of tubercles which spread out, progressing excen- 
trically and multiply within a few weeks; in this way, more or 
less extensive patches are formed or even larger areas may become 
involved. Usually, however, the central lesions flatten, fade and 
undergo sclerotic changes, forming cicatrices even in the complete 
absence of ulceration, while new lesions make their appearance 
at the periphery. This centrifugal or serpiginous development 



TUBERCULO-ULCERATIVE DERMATOSES 



255 



gives rise to circinate forms; these are by no means complete rings, 
but generally more or less semicircular, having a diameter of 2 to 
12 cm, or kidney-shaped and, through confluence, polycyclic con- 
figurations (Fig. 88). Their border is marked by a usually inter- 
rupted zone of isolated or confluent tubercles. 

Occasionally, the eruption of syphilitic tubercles may present this 
circinate arrangement from the start. In these cases, the central 
area shows normal skin. When the circination is the result of 
centrifugal extension of the process, its center is, on the contrary, 
often depressed, slightly adherent and not readily folded; it may be 
distinctly sclerotic or interspersed with cicatricial stars and streaks; 
its color is earthy rather than white, often mottled with purplish or 




Fig. 88. — Tuberculo-circinate syphilides of the left hip. 



brownish shades. The reappearance of tubercles on the cicatrix 
is rare in the tuberculo-circinate syphilides; whereas, on the con- 
trary, this occurrence is frequent in lupus serpiginosus. 

After recovery, the tubercular border has disappeared, but the 
persisting cicatrix may still present a very characteristic appear- 
ance. 
Various forms of tubercular tertiary syphilides may be described : 
The tuber culo-squamous form, with grayish, more or less abun- 
dant, adherent scales, is very common, more so than the tuberculo- 
psoriatiform variety, with abundant nacreous scales and barely 
perceptible infiltration; it is distinguished from psoriasis by the 
small number of the patches, their configuration [and location] and 
sometimes by the presence of cicatrices. 



256 TUBERCLES AND TUBERCULO-ULCERA TI VE DERMA TOSES 

When the tubercles become eroded and covered with an adherent 
dirty brownish crust, the outcome is the tuberculo-crusted form, 
which is connected by imperceptible transition with the tuberculo- 
ulcerative form. In the latter, the crusts are found to cover round, 
perpendicular-walled ulcerations containing a sanious pus. 

These various forms are usually circinate. There also occurs, 
notably on the nose, the forehead and chin, a .superficial tubercular 
syphilide, composed of large, smooth, dusky red tubercles, which 
may be agminated or sometimes confluent in an infiltrated patch. 
The latter is apt very closely to simulate rosacea in the stage of 
rhinophyma; when it appears that the center has a tendency to 
become sclerotic and depressed, this fact furnishes a valuable 
indication in favor of syphilis; but a careful investigation may be 
necessary. 

Certain tertiary syphilitic ulcers, characterized by their indurated 
base, sharp outlines and their course, may be considered as tuber- 
culo-ulcerative syphilides with indistinct and primarily confluent 
tubercles (Fig. 98). The same remark applies to chancriform 
syphiloma. 

The diagnosis of tubercular syphilides can very often be based 
upon their objective appearance; not uncommonly, they put the 
alert observer on the track of an undetected long-standing 
syphilis. In other cases, the diagnosis will be confirmed by the 
complete examination of the patient, the anamnesis and sero- 
diagnosis, with examination by biopsy if necessary. 

Specific treatment will cure these lesions in from two to four weeks. 

Lupus Tubercles. — Lupus vulgaris is one of the most attenuated 
forms of bacillary tuberculosis of the skin. Its characteristic 
lesion consists of a tubercle possessing certain special features. 

In order to avoid the ambiguousness resulting from the double 
meaning of the word tubercle— bacillary tubercle and dermatological 
tubercle — it has been recommended to designate the eruptive lesion 
of lupus as lupoma. 

All cases of lupus begin as a minute lupoma, which grows 
to the size of a pin-head, then of a lentil, while other similar 
lesions more or less rapidly originate in its immediate circumfer- 
ence or in its vicinity. Sometimes, lupus begins in two or three 
distinct foci, or exceptionally in the form of an extensive eruption. 
Lupomas may accordingly be found isolated or conglomerated in 
patches around which a few aberrant lesions are apt to appear. 

Typical I lipomas are rounded tubercles, the size of a- pin-head 
to that of a large pea, more or less prominent, or on the contrary, 
perfectly level with the normal skin; their color is a yellowish, 
sometimes purplish or dusky red; their surface is smooth and 
shining, or scaly, eroded, crusted or ulcerous; their consistence is 



T UBERC ULO- ULCERA TI VE DERMA TOSES 



257 



remarkably soft, compressible, velvety; they are easily penetrated 
with sharp instruments; they are often tender on touch. 

When a lupus tubercle is subjected to vitropressure or diascopy, 
to drive out the blood, its tissue is seen through the glass slide 
to be of a translucid deep yellow color, comparable to barley 
sugar or apple jelly, distinctly outlined from the creamy white 
surface presented by the normal derma. This pathognomonic 
transparency of the compressed lupoma, which is due to the 
local disappearance of the elastic and connective-tissue network 
(Fig. 89), is easily distinguished from the opaque coloration shown 
under the same conditions by a pigmentary spot or a soft verrucous 
nevus. 

b 




f ,-.:v- ■ •■%-'• 



Fig. 89.— Histology of lupus tubercle. Nodular lupoma of the cheek. Stained 
with acid orcein and polychrome blue. The tuberculous newgrowth occupies 
the entire thickness of the derma and results from an agglomeration of tubercles 
such as those seen in Fig. 93. a, collection of epithelioid cells; b, giant cells; 

c, infiltrate of lymphocytes and plasmocytes forming a finely granular network; 

d, d, elastic and connective-tissue framework of the derma, plainly seen to be inter- 
rupted at the level of the tubercle (accounting for the softness and transparency of the 
latter) ; e, tense thin epidermis almost eroded on the surface of the lupoma; /, /, rows 
of lupous infiltration, seen extending into the hypoderm or (/') around a hair 
follicle. X 15. 

Lupoma, as a rule, has a tendency to persist indefinitely, gradu- 
ally extending at its periphery and becoming confluent with neigh- 
boring lesions. The duration of its course extends over months, 
years or decades. However, even in the absence of all therapeutic 
intervention, two contingencies may arise: 

Some cases, so-called resolving lupus, will heal spontaneously 
and become cicatrized, the interstitial sclerosis more or less 
completely strangling and extinguishing the cellular newforma- 
17 



258 TUBERCLES AND TUBERCULO-ULCERATIVE DERMATOSES 

tion. This spontaneous cicatrization usually takes place in 
the center of the patch, while the border continues to proliferate 
(Fig. 168); lupomas are often seen to persist or reappear in the 
cicatrix, which is smooth, white, pearly and more or less flexible. 
This last-named fact is of positive diagnostic value in the differen- 
tiation from circinate and serpiginous syphilides. The treatment 
of lupus by scarification, punctate cauterization, light- and radium- 
therapy, etc., aims at stimulating and favoring the process of 
cicatrization, which is the natural mode of cure. 

On the other hand, the lupoma may undergo necrosis and ulcera- 
tion. The tendency to central necrosis which belongs to all processes 
caused by the tubercle bacillus is relatively much less marked in 
lupus than in the other forms of cutaneous tuberculosis. In some 
cases, however, it may become more pronounced, giving rise to 
restricted, rarely extensive or even enormous destruction of tissue; 
the latter being characteristic of lupus exedens and vorax. The 
features of lupus ulcerations will be discussed elsewhere in this book. 

Tubercles of Leprosy. — The tubercles of leprosy, or lepromas, 
originate either on erythematous pigmented spots or on the healthy 
skin. They may appear separately and insidiously, or in crops 
of numerous lesions, distributed with a certain symmetry on the 
face ! Fig. 175), on the limbs, or in any region of the body. 

Their usual appearance is as follows: Their size varies from 
that of a hemp seed to that of a large almond; their shape is 
hemispherical; their elevation is variable; the color is a dull pink, 
or purplish, or brownish; their surface is smooth, always hairless, 
sometimes oily or scaly; their consistence is firm at the onset, but 
rather sottish and shrunken often after the lapse of some time. 

Their principal properties are: (1) They are almost invariably 
anesthetic toward pricks or burns, sometimes after a temporary 
stage of hyperesthesia; (2) they are histologically composed of 
collections of lepra cells, teeming with Hansen's bacilli. 

Lepromas may become confluent in lobulated tumors, or they 
may spread out in patches of variable extent, moderately promi- 
nent, with a smooth or irregular surface interspersed with telan- 
giectases, etc.; when they occur in patches they are designated as 
leprous infiltrations or surface lepromas. 

The duration of leprosy tubercles is usually very long, but follows 
no rule. They may disappear through absorption, leaving a 
white or pigmented cicatrix; this scar of leprosy infiltrations bears 
the name of leprous morphea. 

They may also undergo suppuration and ulceration; a primarily 
superficial erosion increasing in depth and growing into an irregular 
deeply excavated ulcer, with swollen margins, and a sanious floor, 
sometimes becoming phagedenic and mutilating. 



TUBERCULO-ULCERATIVE DERMATOSES 259 

Lepromata are characteristic of the tubercular or generalized 
cutaneous form of leprosy and are also encountered in the mixed 
form (Chapter XXVII). 

Local treatment of leprosy tubercles yields very satisfactory 
results. They may be treated with salves or plasters containing 
strong reducing agents, or preferably by cauterization with the 
galvanocautery, which leads to their prompt subsidence. [High- 
frequency and radiotherapy are valuable measures, but it need 
hardly be said that local treatment of a few nodules has little or 
no effect on the course of the disease.] 

Cutaneous Sarcoids or Lupoids. — The eruption, which was first 
described by Boeck (1899) under the name of multiple benign cuta- 
neous sarcoid, then as benign lupoid, manifests itself in the form of 
lenticular or larger tubercles, which never become ulcerated. 

General remarks on the sarcoids will be found further on and are 
applicable to the lupoids, which in the main represent merely a 
superficial dermic type of sarcoid, with lesions of small dimensions, 
affecting more particularly the face and the upper limbs. 

A distinction is made between two principal forms: 

1. Disseminated Miliary Lupoid. — The eruption consists of hemi- 
spherical elevations, the size of a millet seed to that of a large pea, 
of a pinkish, then livid and finally brownish color, with a smooth 
or very slightly scaly surface, of semi-solid consistence. On vitro- 
pressure (compression under a glass slide) their- tissue is less trans- 
parent than that of a lupoma and often seems to be made up of 
separate granules. 

The eruption is symmetrical and situated on the face, the 
shoulders, the wrists (Fig. 90) and in general on the extensor sur- 
face of the upper limbs; more rarely, lesions are noted on the scalp, 
the back, or the lower limbs. It comes on in a few weeks, but 
increases during months and years through growth and multipli- 
cation of the lesions. In the course of time, the latter become 
flattened, spreading out in nummular, sometimes marginated, spots 
and finally become obliterated, leaving an atrophic often not very 
noticeable cicatrix. The lesions are accordingly tubercles, in the 
dermatological sense of the term. They never ulcerate, in notable 
contradistinction to the lesions of acnitis. 

The duration of the disease when left to itself is very variable, 
from five to ten years or longer. It is observed much more fre- 
quently in women, between the ages of fifteen and forty years, than 
in men. The lymphatic glands are sometimes enlarged. In a 
considerable number of the cases, the patients are evidently suffer- 
ing from glandular or visceral tuberculosis. 

The histology of lupoid tubercles is characteristic. The derma 
is found to contain large lobulated or branching collections formed 



260 T UBERCLES A XD T UBERC ULO- ULCER A TI VE DERMA TOSES 

chiefly of epithelioid cells, lymphocytes and a few rare giant cells; 
these collections arc separated by connective-tissue strands, in 
which practically no trace of inflammation is demonstrable. 

Several modes of treatment have proved efficient, notably intra- 
muscular injections of calomel, tuberculin injections and, according 
to Boeck, arsenic medication; the best method of treatment actually 
consists in combining aovarsenobejizol injections with tuberculin, 
injected in very small doses. It goes without saying that the 
hygienic condition of the patients must be supervised. 




Fig. 90. — Disseminated miliary Lupoid. Multiple benign cutaneous sarcoid of 
Boeck. 



2. Nodular Lupoid. Nodular lupoid and lupoid in patches 
(large nodular form of Boeck) is less well known. It consists of 
hemispherical, purplish or brownish red elevations, the average 
size of half a ha/el-nut, or in other cases of irregularly outlined 
soft disks; these lesions, to the number of two or three up to ten 
or more, occupy the forehead, the nose, the shoulders, the elbows, 
the neighborhood of the knees, etc. 

Confusion is possible with lupus, superficial tubercular syphilides, 



TUBERCULO-ULCERATIVE DERMATOSES 



261 



or leprosy infiltration. Their histology is related to that of lupus, 
but inoculation of their tissue into guinea-pigs does not produce 
tuberculosis. The tuberculin reaction is not constant. 

I have thought that these two forms of lupoid which 1 have seen 
coexisting with tuberculides or with glandular and pulmonary 
tuberculosis, were tuberculides; this is very probable, but not 
certain. Gorgen Schaumann (January, 1917) interprets the condi- 
tion as a special benign infectious lymphogranuloma, of the same 
character as lupus pernio. 

Granuloma Annulare. — Undoubtedly identical with the ringed 
eruption of Colcott Fox, the lichen annularis of Galloway, the 
sarcoid tumors of Rasch, the nodular and circinate neoplasias of 
Brocq, the granuloma annulare of Radciiffe Crocker is characterized 




Fig. 91. — Granuloma annulare. The patient, a girl of three years, presented seven 
other similar lesions upon the limbs. 



by elevations or tubercles grouped in rings. At the onset, a firm, 
smooth nodule the size of a small pea develops rather rapidly; by 
eccentric growths, or by accession of other nodules, this becomes 
transformed into a ring (Fig. 91); the color is a pale or dull pink; 
there is absolute painlessness. The course is very slow, lasting 
months or years ; the lesions never ulcerate and no scar is left after 
healing. 

This affection, which is rare, is observed in children or adults 
of both sexes and occupies more particularly the hands, the finger- 
joints and the wrists as well as the ankles, but also the elbows, 
the knees, the buttocks, the nape of the neck, exceptionally the 
face. As a rule, the lesions are few in number. Histology shows 
a perivascular infiltration of lymphoid and epitheloid cells, deeply 
situated in the corium; the epidermis is intact. 



202 TUBERCLES AND TUBERCULO-ULCERATIYE DERMATOSES 

Granuloma annulare in many respects approximates the sarcoids 
and the lupoids. Graham Little, in his very complete study of 
the subject (1908) is inclined to consider it as a tuberculide. It is 
treated with reducing plasters and the same general medication as 
the sarcoids. 

The erythema elevatum diuHnum of R. Crocker is probably merely 
;i disseminated or grouped but not annular variety of the same 
affection. 



CHAPTER XIV. 
NODES AND NODULES. 

NODULAR DERMATOSES. 

Under the name of nodes I comprise all circumscribed indurations 
of the hypoderm, of whatever character. Nodes may attain the 
size of an egg, or larger; nodules in my nomenclature are those 
having the average size of a pea; nodosities are those having inter- 
mediate dimensions. 

Nodes constitute an elementary dermatological form, a symptom 
comparable to an eruptive lesion. They play a part which must not 
be underrated in the pathology of the skin. In my opinion, they 
must of necessity figure in the morphology of the dermatoses. 

The hyperderm is closely related to the corium by the continuity 
of the connective-tissue and elastic fibers passing from one to the 
other as well as by its blood and lymph vessels; furthermore, the 
bulbs of the largest hairs and the glomeruli of the large sweat glands 
are imbedded in the hypoderm. 

On account of this inter-relation of tissues and vascular supply, 
pathological processes are very apt to invade the two layers together 
or successively, so that many pathological products are dermo- 
hypodermic. 

The group of nodes, formerly designated as phyma (French: 
noudures; German: Knollen [or Knoten]), is usually subdivided in 
France and classed in part under subcutaneous tubercles, in part 
with gummas or even with tumors, etc. 

It seems to me advantageous to devote a special chapter to their 
discussion. 

Nodes or nodosities may be subdivided according [1] to then- 
volume, their consistence, their more or less distinct limitation; but 
the diagnostic value of these features is insignificant; [2] according to 
their purely hypodermic or dermo-hyper dermic seat, but this seat 
may vary in the course of their development; [3] according to their 
inflammatory, embolic, or neoplastic pathogenesis; this is not easy 
to determine clinically. It is preferable to base a classification on 
their course. 

From this viewpoint, three forms can be distinguished: 

A. Acute nodes and nodosities of sudden onset, are of ephemeral 
or not very prolonged duration, from one to fifteen days, for instance, 
and always terminate by resolution, without suppuration. 



264 NODES AND NODULES 

In tliis acute form, the size of the products varies from that of a 
pea to that of a hen's egg; their consistence is resistant or edematous; 
their boundaries arc indistinct, in the sense of their occupying 
simultaneously the subcutis and the cutis, with somewhat diffuse 
outlines; the skin is usually congested on their surface; they are 
painful to touch. Their abrupt appearance, in certain regions of 
predilection, their distinctly inflammatory character, their tendency 
to resolution are suggestive of their resulting from septic emboli of 
low virulence. 

Among the dermatoses in which acute nodes are met with, I shall 
describe erythema nodosum and rheumatic nodosities. Giant urticaria 
might likewise figure in this connection. 

B. Subacute nodes and nodosities develop insidiously and last 
from a fortnight to several months, or even a number of years. 
Their volume usually varies from that of a hazel-nut to that of a 
green almond; their consistence and the appearance of the skin are 
modified according to their course of development; they are only 
slightly painful. Their pathological anatomy shows them to be 
derived from a subacute inflammatory process, frequently having a 
venous or arterial point of origin and generally of specific character. 
These cases accordingly represent syphilitic, tuberculous, leprous, 
mycotic, or analogous newformations. 

In this subacute form it is necessary to distinguish a group of 
nodosities with a well-marked tendency to softening and ulceration: 
these are designated as gummas. 1 

Under the name of gummas will be accordingly discussed, first 
in order: Syphilitic gummas, tuberculous gummas and finally mycotic 
gummas, a more recent addition to our knowledge. 

Another paragraph will be devoted to a discussion of subacute 
non-gummous nodes. Their course and duration are very variable; 
some of them never become softened and ulcerated, others excep- 
tionally so. Under this heading I group: the nodular syph Hides, 
the sarcoids, which are probably hypodermic tuberculides, and the 
hypodermic lepromas. 

C. If it were desirable to establish a group of chronic nodes or 
nodosities, persisting indefinitely, one might do so at the expense 
of the hypodermic tumors, which exist in all varieties of size and 
consistence. Among such tumors as are sometimes capable of 
giving rise to serious diagnostic difficulties, the following may be 
mentioned. 

Certain subcutaneous hard fibromas; many molluscoid nevi and 
fibroma molluscum, such as those of Kecklinghausen's disease; a 

1 The student's attention must be called to the fact that the French employ the 
term Gomme (gumma) in a wider sense than is customary in English. The sig- 
nificance of the term i« obvious from the text. 



ACUTE NODULAR DERMATOSES 265 

considerable number of cysts; a few deep epitheliomas, cylindromas 
and metastatic carcinomas; lipomas, myomas, calcareous tumors, 
deep angiomas and many sarcomas (Chapter XXXI). 

ACUTE NODULAR DERMATOSES. 

Erythema Nodosum. — This affection is usually considered as a 
simple variety of polymorphous erythema; but it certainly represents 
the most individualized type of the disease. 

Erythema nodosum is characterized by an eruption of nodosities 
or nodes, dermo-hypodermic from the start, rounded or oval, 
from the size of a bean to that of a large nut, of pinkish, carmine- 
red or purple color, rather prominent, not very distinctly outlined, 
painful to touch. They appear in a few hours, often with general 
disturbances consisting of fever, malaise, prostration, rheumatoid 
pains or actual arthritides; their number varies from a few lesions 
to about thirty; they are found scattered, more rarely arranged in 
groups on both legs, on the back of the feet, the thighs and sometimes 
on the forearms, the arms and the buttocks. The bluish color of the 
lesions, which often does not disappear on pressure, is due to inter- 
stitial hemorrhage ; it undergoes the color variation of blood in course 
of absorption and has given the name of contusiform dermatitis to 
this affection. 

The topographical distribution of the eruption, which is practically 
always chiefly localized on the legs, its spontaneous onset, its course 
and its duration which as a rule does not exceed two or three weeks, 
permit it to be easily distinguished from traumatic contusions, 
gummas, sarcomas, etc. 

The etiology of this eruption agrees in indefiniteness with 
that of polymorphous erythema; sometimes it becomes associated, 
moreover, with other manifestations of this erythema. It may be 
observed in the course of septicemias or toxicodermias, notably 
in iodism. Its frequency has been commented upon in venereal 
clinics, among patients suffering from gonorrhea or syphilis. 
Mauriac and others, without sufficient reason, have actually admitted 
the existence of a syphilitic erythema nodosum. Formerly, all 
nodular erythemas were regarded as rheumatic. There is now a 
tendency to hold tuberculosis especially responsible; in support of 
this association, the practically general significance of which he had 
asserted since 1907, Landouzy recently reported a case in which, 
with his collaborators, he discovered a Koch's bacillus in a blood- 
vessel and successfully tuberculized a guinea-pig with a portion of 
the same nodule removed for biopsy. 

The pathological anatomy of the nodes of erythema reveals an 
acute inflammation of ordinary type, with extravasation of red 



206 NODES AND NODULES 

corpuscles and a perivascular infiltration of round cells between 
the adipose lobules; these lesions necessarily suggest an origin from 
microbic emboli, placing them in the class of "phlebitides of the 
cutaneous veins," studied by Philippson. Although it seems to be 
an established fact that a transitory tubercular bacillemia is 
responsible in a certain number of cases of nodular erythema, it 
must not be overlooked that the immediate prognosis of this 
affection is in the main always favorable and that the prognostic 
significance of this blood infection must not be overrated. 

The treatment is that of polymorphous erythema; rest is especially 
necessary. 

Rheumatic Nodosities. — The nodosities known under this name 
must be approximated to erythema nodosum. Several types have 
been described, all equally uncommon. In some arthritics suffering 
from subacute rheumatism and intestinal dyspepsia , I have observed 
the appearance of crops of nodules the size of a pea, subcutaneous 
and without change of color of the skin, or intradermic and rose- 
colored, of firm consistence, very painful on palpation. They were 
situated especially around the knees, at the wrists, the shoulders, 
etc., and lasted from twenty-four to forty-eight hours. 

Fereol observed non-erythematous, very transitory, painless 
nodosities, adherent to the skin, located especially on the forehead, 
but always in small numbers. 

The type pointed out by Meynet concerned deeply adherent, 
hard, elastic, or edematous subcutaneous nodosities, without 
reddening of the skin and slightly painful. Their volume varies from 
that of a pea to that of a walnut. The crops consist of a fairly 
considerable number of lesions, situated especially over bony pro- 
tuberances, more particularly on the skull. Their duration is from 
a few days to several weeks. Confusion must be guarded against 
with gummas or with tumors. 

Possibly these clinical forms are varieties of the same species, 
but it is more probable that this syndrome expresses the result of 
benign microbic embolisms of variable character. 

The treatment consists in the administration of salicylates and 
calcium salts. 

GUMMAS. 

Gummas are nodular pathological products, of infectious character 
and subacute behavior, the course of which comprises four stages: 
(1) Development; (2) softening; (3) ulceration and evacuation; 
(4) repair. They are situated in the subcutis, where they originate 
primarily around the blood and lymph vessels of this tissue; some- 
times, they may reach it secondarily to a process of the same char- 
acter developing in a subjacent organ, periosteum, gland, etc. 



GUMMAS 267 

Many authors, who regard the essential feature of a gumma as 
consisting of its special evolution, rather than of its hypodermic 
seat, describe dermic gummas, developing in the cutis; this term is 
interchangeable with tubercles. All that need be said is that 
tubercles occasionally follow an evolution like that of gummas. 

Hypodermic gummas, or true gummas, which are alone discussed 
here, are syphilitic, tuberculous, or mycotic. 

Syphilitic Gummas. — These represent typical lesions of this 
group. The gumma begins as a limited induration of the hypoderm, 
perceptible to the touch before it becomes visible; it gradually 
enlarges, setting up around it an inflammatory reaction, first raises 
and then invades the derma and finally almost invariably opens 
externally through a crater-shaped ulceration. 

In the developed stage, the nodule is of firm consistence, the size 
of a pea to that of a walnut, indolent and movable. The mass 
becomes pasty, then fluctuating, superficially and sometimes deeply 
adherent; the skin becomes reddened and thinned. Up to this time, 
absorption may occur without leaving a cicatrix, both spontaneously 
and especially with the help of specific treatment. 

More frequently the skin, raised and eroded from below, becomes 
perforated on top of the protuberance; ulceration occurs and leads 
to the escape of a turbid or purulent yellowish ropy [gummy] fluid. 
The orifice enlarges, remaining round, of nummular dimensions; 
its borders are thin, red, overhanging or perpendicular; the cavity 
is deep, cup-shaped ; the floor is uneven, roughened, covered with a 
yellowish-white substance, a sort of core, which is gradually elimi- 
nated with the discharge; the base is of pasty consistence and tender 
on pressure. The corresponding lymph nodes are not enlarged. 

In the stage of retrogression, the granulating floor becomes raised 
to the level of the borders where epidermatization begins, concen- 
trically retracting and finally cicatrizing the ulcer after the infiltra- 
tion has disappeared. The redness is replaced by a persistent 
pigmentation which surrounds the white and smooth cicatrix. 

This evolution extends over a space of time from fifteen to forty- 
five days. 

Syphilitic gummas are tertiary manifestations. Sometimes they 
are precocious, appearing in the second half-year after infection, 
and in this case they are called secondo-tertiary, according to Four- 
nier's expression. Although especially frequent in the third and 
fourth year, they may still occur after ten or fifteen years or 
more. 

They may be situated anywhere, rather commonly on the forehead, 
on the scalp, at the lips, the genitals; they are often multiple or 
develop in close succession to the number of from two to ten or 
thereabouts, rarely more. 



2G8 NODES AND NODULES 

Gummas of the tongue are rather rare. They appear in the form of 
one or several hard intramuscular nodes the size of cherry pits on 
hazel-nuts, studding the tongue and causing more inconvenience 
than actual pain. They open as large ampullary or crater-shaped 
ulcers, which heal leaving a very minute cicatrix. It is important 
to distinguish them from the sclero-gummous ulcer*. 

Gumma.'! of the palatine velum are rarely discovered before they 
ulcerate. They give rise to merely slight inconvenience during a 
week or two, then perforation of the palate suddenly occurs without 
pain, often during a meal, manifesting itself by the return of liquids 
through the nasal fossa 1 and by nasal speech. The gravity of this 
complication is due to these functional disturbances, which are 
persistent, cicatrization taking place without closing the perforation. 
Recourse must be had to a [plastic] operation or a prosthetic appa- 
ratus. Perforation of the palatine velum has long been considered 
as a reliable stigma of syphilis or congenital syphilis. It has been 
reported under other conditions, notably after scarlatina (?). 

In the treatment of gummas, incision of the swelling has no 
advantages and is only too often practised erroneously. Even 
total excision, with careful suturing of the wound, would be 
preferable; but syphilitic gummas, even after softening has occurred, 
heal as a rule remarkedly well under specific treatment in all its 
forms. The importance which was formerly attached to iodin 
in the treatment of gummas, is undoubtedly due to the confusion 
which prevailed between syphilitic gummas and those now known 
to be of mycotic character. Very dilute local injections of soluble 
mercurial salts are very efficient and may be utilized. 

Tuberculous Gummas — also known as scrofulo-tubercular gummas, 
or abroad as scrofuloderma — differ from the preceding by a few 
details in their objective appearance and by their more gradual, less 
continuous evolution. 

The hypodermic nodosity which marks the onset of a tuberculous 
gumma, is sometimes adherent from the start to the deep aspect 
of the derma, which rather early presents a lavender, purplish, or 
livid hue. Softening often begins superficially without affecting the 
entire indurated mass; it may be absent or indefinitely delayed. 
The fluid is sanious or even serous, turbid and mixed with blood. 
Ulceration is frequently of an irregular configuration, with soft, 
detached, purplish borders; the cavity is irregular, sinuous, some- 
times sending fistulous tracts in different directions; it is lined with 
gray or purplish filamentous detritus; its walls are softened or 
locally indurated. 

It is not uncommon for the multiple orifices of the same gumma, 
or of neighboring gummas united in a gummous infiltration, to inter- 
communicate by sinuous tracts which lead into the same cavity; 



GUMMAS 269 

they are separated by bridges which may persist even after cica- 
trization or may rupture as the result of erosion. 

Tuberculous gummous ulcers accordingly often have sinuous and 
ragged, undermined, pale or dark purple borders and an extremely 
irregular floor. The discharge is very variable, distinctly purulent, 
or serous and mixed with blood. The crusts possess corresponding 
features. 

These ulcers may invade the tendon sheaths, the joints and the 
bones, from which they may also be derived. They are sometimes 
transformed into fungoid tuberculosis or lupus. When they heal, 
the cicatrix is usually irregular, often adherent in the depth of the 
tissue, honey-combed with fibrous islands, dentated at the periphery 
or undermined by fistulous tracts which pass under cicatricial 
bands. The borders remain for a long time purplish, later becoming 
pigmented. 

The course is slow, with exacerbations and remissions, lasting 
several months or sometimes years. 

Scrofulo-tubercular gummas are frequently but not invariably 
encountered in individuals whose general condition is unfavorable, 
who suffer from visceral tuberculosis or especially from bony or 
glandular tuberculosis. Children and youthful individuals are the 
most susceptible. They number from one or two to about ten, 
rarely more lesions presenting different stages; they occupy espe- 
cially the extremities or the neck, sometimes the trunk, but often 
the face. They are disseminated, more particularly in children 
and youthful individuals; or they may show a regional distribu- 
tion, especially when they are consecutive to a deep focus and, 
in these cases, assume a lymphangitic type. 

Tuberculous gummous lymphangitis, practically limited to the 
extremities, originates from a lesion of the extremities, usually an 
anatomical tubercle, tuberculosis verrucosa, spina ventosa, or 
tuberculous caries of the bones. Arranged along the tract of the 
lymphatics coming from this primary focus, a series of several 
gummas begins to develop. A lymphatic strand may occasionally 
be felt which unites these secondary foci. The corresponding 
glands are usually indurated, sometimes suppurating or fistulized. 
The duration of this trouble is indefinite; it may be prolonged until 
death occurs from vertebral or visceral tuberculosis and from 
cachexia. 

The 'pathological anatomy of tuberculous gummas will be dis- 
cussed elsewhere in this book. It will be seen that they usually 
contain Koch's bacilli, although in moderate numbers, and that 
their tissue causes tuberculosis in guinea-pigs inoculated with it. 
However, clinically identical products are also met with whose 
scrapings and sections contain no bacilli and whose inoculation into 



270 XODES AND NODULES 

animals remains negative. This justifies the conclusion that the 
clinical picture of scrofulo-tuberculous gumma may be produced by 
hypodermic tuberculides. 

The same picture may, moreover, be very closely simulated by 
mycotic gummas; a thorough examination of the patient in regard 
to his antecedents and the coexistence of internal tuberculous lesions, 
is imperative for the diagnosis, although in many cases only the 
laboratory findings are capable of confirming it. 

Mycotic Gummas.- — Several infections through fungi may give 
rise to genuine gummas. Sporotrichosis is the best known of these 
and also the most common. Sporotrichotic gummas are sometimes 
disseminated, sometimes lymphangitic and regionally distributed. 
When disseminated, they may be found anywhere, in variable 
number; they are indolent and develop in six to eight weeks. Firm 
at first, then soft, they persist for more or less time in this condition, 
then undergoing ulceration and evacuation. Their liquid contents 
are at first viscid and gummous, later on purulent and thickened. 
The ulcer may be covered by a crust, of ecthymatous appearance, or 
again very deep, of rounded or irregular circumference, with under- 
mined margins; sometimes, the floor is covered with granulation or 
even large proliferations. This ulcer remains stationary a long time, 
unless treatment intervenes (p. 605). 

Sporotrichotic gummous lymphangitis consists of a series of 
gummas developing in the centripetal lymphatic territory of the 
initial focus (Fig. ISO), which may be dermic or hypodermic, or 
bony, etc. A moniliform strand may connect the lesions. The 
corresponding glands are often, but not always swollen and 
enlarged. 

Actinomycosis, in its primary cutaneous form, often has the 
appearance of a hypodermic nodule, with a pinkish surface, hard 
and practically painless, which softens at its center and ulcerates, 
but from which a sanguinolent discharge escapes instead of pus; 
the orifice remains fistulous. Neighboring nodules form and become 
agglomerated with the first. The lymph glands remain intact. The 
site of the lesions is most commonly the cervico-facial region (p. 599). 

Some blastomycoses may give rise to gummas. This is particularly 
true for the Buschke type, of which a few rare observations have 
been recorded; it is a febrile infection, seriously interfering with 
the general health. The origin, as a rule, is in the osseous system 
whence there follow multiple disseminated gummas. [It would 
seem probable that the point of entry for the organisms is an insig- 
nificant cutaneous lesion, though a periosteal swelling may be the 
first lesion to attract attention] (p. 603). 

Mycetoma, or Madura foot, is a local mycosis characterized by 
nodosities which become bullous on their surface, then softened and 



SUBACUTE NON-GUMMOUS NODES 271 

ulcerated, accordingly representing true gummas; their agglomera- 
tion may result in a monstrous deformity. 

In "picm-bois," a Leishmaniosis, I have observed a sort of gumma 
with a lymphangitic distribution. 

For the diagnosis and treatment of these mycotic gummas, the 
reader is referred to Chapter XXVIII. 

[All the forms of cutaneous and subcutaneous tuberculosis are 
relatively rare in America and blastomycosis seems to be more 
common than sporotrichosis while the converse is true in France 
and Germany.] 

-SUBACUTE NON-GUMMOUS NODES. 

Nodular Syphilides. — This name, as well as that of nodular 
syphilitic phlebitis, is applied to hypodermic nodules which some- 
times occur in the course of the secondary manifestations of severe 
syphilis, associated in most cases with a profuse eruption of lentic- 
ular papules. 

The nodules are hard, distinctly outlined, movable under the skin 
and on the underlying tissues, round, spindle-shaped or flattened, 
the size of a large pea to that of an almond ; the skin on their surface 
is normal or slightly reddened. They are painless when left alone, 
but slightly tender on pressure. They are situated in variable 
numbers, from a dozen to twenty at most, on the extremities, rarely 
elsewhere. 

Their size, their topography, their number, their free mobility, 
and especially their course, serve to distinguish them from the 
nodosities of erythema nodosum and syphilitic gummas. 

In a case, observed with Civatte, the histological examination 
enabled us to recognize distinctly the presence of a syphilitic 
newformation (of the same type as the lenticular papule) which 
developed in the wall of the subcutaneous veins giving rise to 
thrombophlebitis. 

The evolution of these nodular phlebitides is rather slow. They 
have practically no tendency to undergo softening and ulceration, 
but in the absence of treatment will persist for many weeks without 
change. Under the influence of specific treatment, they very 
promptly disappear. 

Leprous Nodosities. — These products, known also as hypodermic 
lepromas, often accompany the dermic leprous tubercles in moderate 
number. In more interesting but less common cases, the nodosities 
occur without tubercles, coincidently with erythemato-pigmentary 
leprides. They can be detected only after careful search; as stated 
by Leloir, they may be felt rather than seen, for they barely raise 
the skin, 



272 NODES AXD XODULES 

Hypodermic lepromas are situated chiefly on the buttocks, the 
back, the external aspect of the extremities, on the face, and very 
frequently on the ear-lobules, which appear as if stuffed with shot. 

They are circumscribed, rounded or oval, the size of a pea to that 
of a walnut, sometimes conglomerated, or they may be diffuse 
(leprous infiltrations) in slightly raised, flat or uneven patches. 

At the onset, the circumscribed nodules are firm and elastic and 
at first movable; later on they become softened and adherent to the 
skin, which turns red on the surface. Nodules and infiltrations 
may ulcerate, thus becoming entitled to the name of leprous gummas 
or gummxms infiltrations of leprosy; they contain a grumous pus very 
rich in Hansen's bacilli. They often seem to persist indefinitely, 
or they undergo absorption, leaving a sclerotic or even keloid 
cicatrix, or no trace of their former presence. 



SARCOIDS. 

This term was devised by Kaposi to designate newformations 
resembling sarcoma. Boeck (of Christiania) described under the 
name of multiple benign cutaneous sarcoids, eruptions of tubercles 
resembling lupus; more recently, he called them lupoids. Other 
newformations have also been designated under the name of 
sarcoids. In a report to the XVI International Medical Congress 
(1909) I pointed out that until the etiology and real character of 
these new-formations are elucidated, the denomination sarcoids is 
indispensable. 

It designates a group of connective-tissue newgrowths which 
manifest themselves clinically in the form of nodes, nodosities, 
nodules or tubercles, usually multiple, painless, of slow or even 
chronic, but not unlimited development. They are benign in the 
sense that they have no tendency toward softening and ulceration, 
do not recur locally after removal, do not give rise to visceral 
metastases and do not notably affect the general health. They are 
subject to retrogression, either spontaneously or under the influence 
of arsenical agents, mercury, tuberculin, etc. 

Anatomically, these sarcoids are made up of cellular collections 
or infiltrations often of a tuberculoid structure, insinuated into the 
framework of the derma or the hypoderm — which distinguishes 
them from the sarcomas, whose constituents are arranged in coherent 
and homogeneous masses. 

The following pathological types come under this definition: 

1. Cutaneous Sarcoids. — Cutaneous sarcoids of Boeck, or lupoids. 
Their intradermic seat and their small dimensions have led me to 
group them among the tubercles (p. 2o9). 



SARCOIDS 273 

2. Hypodermic Sarcoids. — As described by me with Roussy (1904 
to 1906), these are painless subacute or chronic newformations, 
the size of a bean to that of a walnut, or larger; they often become 
confluent in large uneven patches and nodular strands. The skin 
over them is raised, of normal, lavender, or dull red color. At 
first sight, they might be mistaken for tumors, but they have no 
unlimited extension. They are observed in adults of both sexes; 
their duration is indefinite. 

These sarcoids are generally grouped in certain regions, and have 
a tendency to a symmetrical arrangement. I know of two seats 
of predilection: on the one hand, the costal region, the flanks, and 
the scapular region, on the other, the anterior aspect of the thighs, 
and the lower portion of the abdomen. However, they are also met 
with elsewhere, on the arms, the forearms and even on the scalp. 
This type is relatively rare. 

These sarcoids must not be confused with tumors of various kinds 
of the thoracic wall, nor with axillary, cervical or other adenop- 
athies. On the thighs they may be very closely simulated by 
nodosities due to the injection of camphorated oil, or other hypo- 
dermic injections, which sometimes persist indefinitely. The 
appearance of genuine sarcoids, however, seems to be absolutely 
spontaneous. The paraffinomas will be mentioned further on. 

3. Disseminated Nodular Sarcoids. — These are nodes or nodules 
which develop successively in crops and are scattered particularly 
over the extensor surface of the extremities more or less symmet- 
rically, but also on the trunk and sometimes even on the face. 
They usually number from about ten to thirty, but I have counted 
over one hundred and fifty in one case (Fig. 92). The skin over 
them is of normal color, or pinkish, or brownish-purplish, raised or 
on the contrary slightly depressed and on pressure may present the 
appearance of orange-peel. Their consistence is very hard, or some- 
what doughy; with rare exceptions they are painless. Very rarely, 
some may become eroded on their surface and covered with a crust. 
They are observed at all ages, in both sexes, and are not very 
uncommon [in France]. They may disappear spontaneously. 

These disseminated sarcoids possess a great analogy with scrof ulo- 
tuberculous gummas in the firm stage ; they differ f rOm them in that 
they do not soften and ulcerate; but these two pathological types 
may exist together. 

They also possess such marked analogies with the erythema 
induratum of Bazin that I have thought these two affections might 
be identical; erythema induratum would then be merely a particular 
form, an objective appearance of disseminated sarcoid. It is, 
however, entitled to separate mention. 

18 



274 



NODES AND XODULES 



4. Erythema Induratum of Bazin. — Under the name of crytheme 
indure des scrofuleux, Bazin had described more or less deeply 
indurated and imperfectly outlined, pinkish, red orpnrplish patches, 
which are observed in youthful individuals, especially young girls, 
almost invariably occupying the outer and lower portion of the legs; 
they may also be observed on the thighs, on the upper limbs, and 
even on the forehead. Their course is subacute, with congestive 
exacerbations accompanied by throbbing pains; periods of retro- 
gression occur under the influence of rest. 




92. — Disseminated nodular sareoids on the 

aged forty-five years. 



lower abdomen of 



English authors, Colcott Fox and especially -I. Hutchinson, have 
shown that Bazin's disease, as they call it, not infrequently gives 
rise to sluggish and obstinate ulcers (Fig. 102); this is the English 
type, or Hutchinson's type, which in this respect distinctly differs 
from the sarcoids and approximates the tuberculous infiltrations. 

The histological structure of the various sarcoids referred to above 
is not uniform. The structure of the cutaneous sarcoid of Boeck, 
or lupoid, is entirely distinct. The hypodermic sarcoids of the 
1 )arier-Roussy type are to the highest degree tuberculoi 1 in structure 
(Fig. 93), perfect tubercles [in the pathological sense] being found 



SARCOIDS 



275 



in addition to the ordinary lesions due to reaction of the adipose 
tissue, known since Flemming under the name of " Wucheratrophie" 
(proliferative atrophy). The disseminated sarcoids have either 
an analogous structure, or that of inflammatory newformations; 
the whole gamut of lesions may be met with from erythema nodosum 
to the most characteristic tuberculous gummas. In erythema 
nodosum, the infiltration is also more or less ordinary, or else tuber- 
culoid with partial necrosis. Thibierge and Ravaut, Mantegazze 
and Guibert emphasize the vascular lesions, which I was always 
able to demonstrate. 




Fig. 93. — Histology of hypodermic sarcoids. Tuberculoid focus at the 
periphery of a lobulated nodosity of the thoracic region, a, giant cell; b, zone of 
epithelioid cells; c, c, zone of lymphocytes; d, fibrous tissues surrounding the nodosity ; 
e, sclerosis of the adipose tissue; g, collection of epithelioid cells belonging to a neigh- 
boring tubercle. X 130. 



The nature of the sarcoids is obviously infectious and the patho- 
genic mechanism of their origin is undoubtedly through embolism . 
But their etiological connection with Koch's bacillus, which would 
make them tuberculoses or tuberculides, has not been established, 
at least not for all types. Histology, as is now known, does not 
settle the question, for the tubercle is by no means characteristic 
of the bacillary infection, but may occur in the mycoses, in syphilis, 
leprosy, etc. Inversely, the absence of tubercles, according to 
numerous recent contributions in no way excludes the presence of 
Koch's bacillus. 

As regards erythema induratum, its tuberculous nature may be 
said to be an established fact based on its common coincidence with 
visceral, bony, glandular, or cutaneous tuberculosis; or with papulo- 



276 NODES AND NODULES 

neurotic tuberculides and lichen scrofulosorum ; and from its reaction 
to tuberculin. Still more direct proofs have been furnished; its 
tissue infects inoculated guinea-pigs with tuberculosis (Thibierge 
and Ravaut, Carle) and, in a few cases, the bacillus has been 
demonstrated therein (Philippson, Jadassohn). 

Notwithstanding coincidences and transition forms, no such 
definite conclusions can be formulated in regard to the other types. 
It is still desirable, in cases coming under observation, to look for 
the Wassermann reaction, which is negative as a rule, and for the 
tuberculin reaction which is generally positive, as well as to carry 
out the necessary laboratory tests. The solution of this problem 
belongs to the future. 

The treatment of sarcoids with arsenic has been vaunted as 
well-nigh specific; arsenobenzol is sometimes remarkably successful 
(Ravaut); I have obtained excellent results from calomel injec- 
tions; at the same time as Thibierge, I became impressed with 
the rapid efficacy of tuberculin injections in very minute doses, 
especially in erythema induratum; as a rule, a combined medication 
with novarsenobenzol and tuberculin gives the best results. Rest 
and good general hygiene are imperative. In spite of treatment, 
recurrences are to be anticipated. 

The term paraffinoma has been applied to hypodermic lesions 
which are often caused by injections of paraffin; in certain respects, 
these may be compared with artificial or induced sarcoids. About 
fifteen years ago vaselin injections and then injections of paraffin at 
a melting point of 65° or .V)° were recommended for the correction 
of various congenital or acquired deformities, saddle-nose, mis- 
shapen ears, atrophic rhinitis with ozena, bad sears, fistulas, and 
even for the esthetic improvement of the face, the base of the neck 
or the female breast. 

These injections are not devoid of danger. After a few years, a 
progressive swelling with a coppery redness and very painful tension 
may make its appearance at the injected points. Its cause is easily 
recognized from the site and the statements of the patient. 

Histological examination shows a diffuse, nodular, chronic inflam- 
mation, with microscopical abscisses and giant cells, caused by the 
paraffin which has spread between the tissue-meshes and hollowed 
out cavities lined with endothelium. Injections of vaselin or cam- 
phorated oil sometimes produce analogous lesions. Massage, 
electrolysis and aspiration are usually inefficient and it is necessarv 
to resort to surgical ablation. 



CHAPTER XV. 

ULCERATIONS, ULCERATIVE DERMATOSES AND 
CUTANEOUS GANGRENES. 

Ulcerations of the skin are losses of substance due to a patho- 
logical process of molecular destruction or of gangrene, in contra- 
distinction to wounds, which are directly produced by a trauma. 

The term ulcer is reserved more particularly for chronic ulcera- 
tions with a marked tendency to persist a long time or indefinitely. 

Cutaneous gangrene is the mortification or necrosis of a more or 
less extensive portion of the tissues. 

I shall first discuss ulcerations in general and the ulcerative 
process; then the ulcerative dermatoses; finally, gangrene. 

ULCERATION IN GENERAL. 

Clinical Features. — The various ulcerations are differentiated by 
numerous features, which must be kept in mind for the diagnosis. 

1. The variable depth of the loss of substance permits a distinc- 
tion between : excoriations, which are superficial, involving only the 
epidermis and often resulting from a blister, a superficial pustule, 
or a vesicular process; they heal without a scar, leaving a simple 
pigmentary macule; and true or dermic ulcerations, which encroach 
upon or destroy the derma and are necessarily followed by scar- 
formation. 

2. The extent of the ulcerations is rarely of much importance; it 
is useful to know, however, that certain varieties never acquire large 
dimensions, whereas others on the contrary may be of almost 
indefinite extent. 

3. The configuration is geometrical or irregular, rounded, oval, 
polycyclic, reniform, circinate, etc. 

4. The borders may be either sharp or imperfectly outlined, 
perpendicular, detached or overhanging, sloping, raised or flat, 
slanting, everted, fissured, etc. 

5. The floor may be level or uneven, granular, papillomatous, 
"worm-eaten," sinuous, crateriform, raised, etc. 

6. The color of the floor of ulcerations is red, purplish, grayish or 
yellowish. 

7. The discharge is serous, purulent, hemorrhagic or sanious, 
and more or less profuse. 



278 



ULCERATIONS AND ULCERATIVE DERMATOSES 



8. The crusts which resull from the drying of the exudate present 
a variable appearance. Ostreaceous crusts, which arc thicker in 
the center and apparently made up of heaped up disks of dimin- 
ishing size, deserve special mention. They are characteristic of 
the lesion described as rupia by older writers (Fig. 94). Their 
occurrence is noted on ulcerations which increase intermittently, 
such as certain syphilides, more rarely in ecthyma. 

9. The base of the ulcerations is sometime- soft, edematous, in 
other cases infiltrated and more or less indurated. 

10. The periphery varies in color, consistence, condition of its 
surface, etc. 

11. Tenderness, spontaneous or induced, or on the contrary 
anesthesia, are peculiar to certain form-. 





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streaceous crusts in a case of ulcerative secondary syphilides. Syphilitic 
rupia of old authors. 



12. The condition of the corresponding glands deserves attention; 
so also 13) the site and (14) the course of the ulcerations. 

Among these various features, those relating to the borders, the 
configuration, the base and the periphery possess the greatest value. 
They may afford information, to a certain degree at least, as to the 
process involved or show if the ulceration has occurred in healthy 
>kin or at the expense of an infiltration or a tumor. 

As To the topographical seat of the ulcerations, this is one of the 
signs mosl relied upon by the practitioner, often subconsciously, 
l.ut not without reason. The fact that the lesions are situated, for 
example, on the face, the genitals, the legs, or the extremities, in 
itself supplies a valuable indication, often limiting the field of the 
diagnostic possibilities. The only feature of ulcerations, however, 
which in my opinion can be utilized for a rational classification, is 
represented by their course. 



ULCERATION IN GENERAL 279 

Pathogenesis. — The mode of formation of ulcerations is variable. 
Exceptionally, they result from mortification en masse of a more 
or less extensive portion of the tissues; this is what occurs in 
the gangrenous dermatoses. 

Sometimes a dermic ulceration is derived from deep extension 
of an excoriation; or it may apparently develop in healthy skin; 
most commonly it is the result of disintegration or partial necrosis 
of an infiltration (tuberculous syphilitic, leprous, etc.), or of a tumor 
(epithelioma, mycosis fungoides, etc.). 

In all these cases, the loss of substance results from the necrosis 
or necrobiosis of the cellular elements and of the tissue framework, 
followed by their molecular disintegration. 

Without entering into unnecessary details, it is sufficient to 
emphasize that the conditions of the ulcerative process, as far as 
they are known, may be of two orders. One of these conditions 
concerns the germ or virus which may at the same time possess a 
toxic, necrotizing and digestive or lytic property and be able for a 
long time to resist the defensive measures of the organism ; as is the 
case in soft chancre and very probably in phagedenism. 

The other condition refers to the soil and consists of an imperfect 
blood supply, due to preexisting regional vascular lesions (varicosi- 
ties, etc.), or to the effect of the pathological process itself (tubercu- 
losis, syphilis). Sometimes a general metabolic disturbance may 
be held responsible [diabetes, etc.]. 

Disturbances of innervation undoubtedly also play a part, not 
yet fully elucidated but proved by the so-called trophic ulcers, 
such as malum perforans, ulcers of nerve-leprosy, etc. 

Different pathogenic factors are often combined. 

Etiology. — In a general way it may be stated that all agents 
injurious to the tissues may, through their prolonged activity, give 
rise to and maintain ulcerations. They are divided into mechanical, 
physical, chemical and microbic agents. 

Repeated traumatisms, by tools, shoes, bandages, or badly fitting 
apparatus, produce ulcerations. Their seat and form are often 
suggestive. A particular instance of these traumatic ulcers is 
furnished by the setons or issues, which our forefathers believed 
it advisable to establish by means of simple or epispastic agents. 

As regards the induced [or artificial] ulcers which are observed on 
self-mutilators and malingerers and which were formerly referred 
to an assumed hysterical pemphigus, these are outside of any possible 
general description, in view of the variety of means employed and 
their results. 

Crevices, rhagades, fissures or cracks are usually grouped among 
ulcerations, although not resulting from a loss of substance; they 
are rather linear wounds of traumatic origin in a dermic tissue 



280 ULCERATIONS AM) ULCERATIVE DERMATOSES 

the elasticity of which may. however, have beeB impaired by a 
preceding inflammatory process. 

They are met with on the extremities, mi the hands and feet, as 
complications of a hyperkeratosis, or at the circumference of the 
aatural orifice-, at the lips,, especially in scrofulous children, at the 
nipples of wet-nurses, very frequently at the anus, on the prepuce of 
diabetics, etc. Under the influence of movements of extension, the 
keratotic or macerated, sometimes even eczematized epidermis 
cracks and the lesion reaches down to the cutis. The borders of 
the crevices are perpendicular, the floor is bright red, sometimes 
bleeding; pain is often very severe; healing may take place without 
[visible] scars. 




Fig. 95. — Tubular epithelioma in the form of ulcus terebrans 



The pain of cracks or crevices is relieved by local anesthetics, 
cocain and analogous remedies; superficial cauterizations with 
[a 5 per cent, solution of] silver nitrate may sometimes prove useful; 
it often suffices to apply either poultices or emollient dressings, or 
pastes or varnishes containing keratoplasty or keratolytic agents, 
according to the requirements of the case. 

Among the ulcerations resulting from physical agents, those 
due to burn-, frost-bites, .'-rays, etc. (Chapter XXIII) may be 
mentioned. 

Various toxic agents produce pustulo-ulcerative or primarily 
ulcerative lesions, either through ingestion, or more often as the 
result of externa] application. As an example may be mentioned the 
occupational arsenical ulcerations, occurring especially on the hands 



ACUTE ULCERATIONS 281 

and sometimes on the face and the genitals of laborers who handle 
arsenic or its compounds [such as Paris green]. 

The principal factors of ulcerations are microorganisms, which 
are concerned either exclusively and primarily, or in cooperation 
with other causes. This matter will be referred to again in connec- 
tion with the ulcerative syndromes in particular. 

As regards the ulcerations of tumors, their objective features and 
their course are too closely connected with those of the causative 
neoplasms to render a separate description advisable. It is neces- 
sary to state, however, that in some exceptional cases, the ulceration 
so markedly exceeds the neoplastic process that the latter may 
remain unrecognized. This rarely happens in the various sarcomas, 
in mycosis fungoides or in lobulated epithelioma, but is on the con- 
trary very common in tubular epithelioma (Fig. 95), which was 
and still is described in some of its clinical forms under the name 
of rodent ulcer or ulcus epitheliomatosum terebrans. 

Ulcerative Dermatoses. — Based especially upon their course, I 
distinguish between the following groups: 

A. Acute Ulcerative Dermatoses. — They develop rapidly in healthy 
skin, never assume large dimensions, suppurate frankly and freely 
and are usually due to an external local infection. Soft chancre is 
typical of these dermatoses. 

B. Subacute Ulcerative Dermatoses. — They are derived from one 
of the great subacute infections, more particularly syphilis, tuber- 
culosis and leprosy. The ulceration takes place at the expense of a 
preliminary newformation. 

C. Phagedenic Ulcers. — This name is applied to ulcers of rapid 
spread and great chronicity. 

D. Chronic Ulcerations, or True Ulcers. — Their pathogenesis is apt 
to be complicated. 

E. Ulcerations of Mucous Membranes. — The excoriations and ulcer- 
ations of mucous membranes are discussed in a separate paragraph, 
because it seemed to me convenient for the reader to find in one 
place important data on the diagnosis of lesions of the mouth and 
of the genital organs; these data will practically supplement what 
has already been stated on this subject in Chapter XL 

ACUTE ULCERATIONS. 

Soft Chancre. — Soft chancre (ulcus molle) or chancroid, which will 
be described elsewhere from the nosographical viewpoint, develops 
very rapidly, and at the end of two or three days possesses its 
typical features. 

It is a round or oval, relatively deep ulceration, the size of a pin- 
head, a lentil, a dime, or rarely larger. Its borders are perpendicular, 



282 ULCERATIONS AND ULCERATIVE DERMATOSES 

undermined or slightly detached; often they are cracked or fissured. 
The floor is of a creamy yellow or yellowish gray, irregular, "worm- 
eaten." The base is soft, sometimes doughy, but not parchment- 
like or cartilaginous. The circumference is red, slightly swollen. 

Soft chancre lias an abundant, distinctly purulent discharge. 
It is rather painful on touch or when the skin of the region is 
rubbed in moving. It is rarely single; as a rule, several are found, 
originating from the same contagion or from successive auto- 
inoculations. This was humorously expressed by Ivicord when he 
said that the soft chancre is a family man and lives surrounded by 
his children. In some cases, in persons suffering from the itch, for 
instance, over a hundred soft chancres have been counted on the 
same subject. 

The corresponding lymph glands are usually swollen and painful, 
one among them often greatly preponderating. This glandular 
swelling has a marked tendency to suppurate and discharge, under- 
going transformation into an ulcer representing the so-called chan- 
croid bubo of French writers. 

Soft chancres are situated in the genital region in the vast majority 
of cases. They may occupy any point of this region; in men, the 
prepuce, the sulcus coronarius, the frenum, which is very often 
perforated, then divided, or the skin of the penis are involved; in 
women, the vestibule, the labia minora, the fourchette, the pre- 
putium clitoridis and frequently the anus. In the last-named 
localization, which may result from auto-inoculation, the chancre 
frequently appears double, the two folds of the ulcerated surface 
resting against one another, while its swollen lower border produces 
a protuberance resembling a condyloma. 

The neighboring regions — intergluteal fold, internal aspect of the 
thighs, pubis, etc. — are affected in a considerable number of cases. 

Extragenital Soft Chancres are rare. They may be observed on 
the fingers or on the hand (Fig. 90), where they are often misinter- 
preted; also on the face, although the existence of cephalic soft 
chancre was formerly denied. 

The diagnosis is often easy, on account of the distinct objective 
features, the topography, the usual multiplicity, the rapid course of 
the ulcerations and the painful glandular swelling. 

In doubtful cases, absolute certainty can be secured by means of 
two procedures: (1) Demonstration of the specific streptobacillus 
in the pus; (2) experimental auto-inoculation, which is valuable in 
that it provides a conclusive answer within forty-eight hours. 
This inoculation should be made in the deltoid region; as soon as 
it has been recognized as positive, the focus must promptly be 
destroyed by means of the thermocautery. In all doubtful cases, 
such as will be described, the employment of these two diagnostic 



ACUTE ULCERATIONS 



283 



procedures, at least of inoculation, is imperative, as the treatment 
of soft chancre demands much more energetic measures than are 
necessary in the case of the ulcerations which mav simulate it. 




Fig. 96. — Soft chancre of the back of the hand. 



Other Acute Ulcerations. — Mixed Chancre. — The mixed chancre 
of Rollett is not common, but has been observed with some frequency 
during the war. It results from inoculation at the same point with 
the bacillus of soft chancre and the spirochete of syphilis. When 
this inoculation has been simultaneous, a soft chancre develops first ; 
at the end of two to four weeks, the incubation period of syphilis, 
the base of this chancre becomes distinctly indurated, its surface is 
modified to resemble that of a primary lesion and a generalized 
adenopathy develops. The demonstration of the spirochetes in 
such cases is very difficult and the diagnosis usually depends on the 
appearance of a positive Wassermann reaction. 

When the inoculation is successive, namely when an indurated 
chancre becomes infected with virus of soft chancre, which is uncom- 
mon, the transformation occurs in the opposite direction. One 
must avoid the frequently committed error of applying the name 
mixed chancre to a soft chancre occurring in an already syphilitic 
subject, who therefore presents from the start a positive Wassermann 
reaction. The treatment must of course be both local and general. 

Ulcerative Syphilitic Chancre. — The primary lesion of syphilis is, 
as a rule, simply erosive and seems to be an insignificant " sore." 

In exceptional cases, in weakened or exhausted, alcoholic or 
diabetic subjects, in localizations predisposed to irritation and super- 
added infection, indurated chancre becomes ulcerative, deeply 
invading the derma and burrowing both superficially and deeply. 
A "chancre terebrans" may perforate the prepuce or even the urethra 
in men, one of the labia minora in women, etc. The ulcer is painful ; 
its irritable, proliferating, granular floor resembles that of a soft 



284 ULCERATIONS AND ULCERATIVE DERMATOSES 

chancre. The induration of the base, however, is often verymarked; 
the purulent discharge is less profuse than in soft chancre, auto- 
inoculation docs not occur and generalized glandular swelling 
supervenes. 

Ulcerative Secondary Syphilides. 'I heir course may be very rapid, 
or subacute. I shall have more to say concerning them later. 

Ulcerated Herpes. Although herpes is primarily vesicular and 
ordinarily gives rise only to very superficial erosions, these may 
become deep and suppurate under certain conditions of territory or 
of improper treatment. 

The differential diagnosis from soft chancre, often rather difficult, 
pests in such cases on the polycj clic arrangement of the lesions, their 
simultaneous appearance, the persistence of non-infected herpetic 
elements in the vicinity and especially on the negative outcome of 
experimental auto-inoculation on the arm. 

Ecthyma. This consists of an at first bullous or pustular, secon- 
darily ulcerative lesion. It affects especially the lower limbs, some- 
times the trunk and has no predilection for the genital region. 
The ulcers have gently sloping, not perpendicular borders. 

In all the cases mentioned, except that of mixed chancre, micro- 
scopical examination of the pus in smears shows the absence of the 
streptobacillus; inoculation on the arm produces a superficial 
impet igo-pustule, without involvement of the cutis and healing of its 
own accord in at most three or four days. 

SUBACUTE ULCERATIONS. 

Syphilis As a rule, the secondary lesions undergo resolution, the 
tertiary lesions alone being destructive and having a tendency to 
ulcerate. 

Sometimes, however, beginning with the first eruption, the papulo- 
crusted lesions ulcerate under the brownish or grayish crust which 
covers them; at the same time, more or less extensive and destruc- 
tive ulcerations appear on the mucosa'. These eases are described 
;i- syphilis maligna precox. Weakened, undernourished or alcoholic 
individuals are predisposed to it; a special property of the germ has 
often been held responsible and tropical syphilis is of bad repute 
in this respect. However, this special course has also been noted in 
robust individuals who were infected by a syphilis of ordinary 
behavior. So much is certain that the spirochetes are usually rare 
in the malignant syphilides, although inoculation into monkeys 
may yield a positive result. 

Ulcerative secondary syphilides constitute an irregularly scattered 
eruption of ulcerations which develop and enlarge rapidly; they 
have a round or more often oval form, perpendicular purplish 



SUBACUTE ULCERATIONS 



285 



borders, a cupola-shaped floor, filled with sanguinolent pus, and a 
soft base. They are only slightly painful, except in certain 
localities. 

Their peripheral extension and the dessication of the pus which 
they secrete, sometimes give rise to ostreaceous crusts, thicker in 
their center; this picture was formerly designated under the name 
of syphilitic rwpia (Fig. 94). 




Fig. 97. — Serpiginous tuberculo-gummous syphilides. 



Discrete or profuse, sometimes even confluent in places, the 
secondary ulcerative syphilides sometimes co-exist with deep ulcer- 
ations of the mucous membranes and do not readily heal; they 
leave honeycombed dyschromic, sometimes mutilating cicatrices 
which constitute significant stigmata. They are usually associated 
with rapid emaciation, considerable cachexia, fever, albuminuria 
and pulmonary or digestive complications and may lead to death. 



286 



VLCERATIOXS AM) riJ'Eh'ATIYE DERMATOSES 



Malignant syphilis had been observed to be often rather resistant 
to mercury and iodide treatment, and in addition arsenic medication, 
injections of hypertonic sera, a strict hygiene and careful local 
dressings were recommended. The introduction of the arseno- 
benzols has improved the prognosisof this form of the disease; their 
efficacy is remarkable and rapid; it is recommended to combine 
their action with that of injections of soluble mercury or calomel. 

Ulcerative tertiary syphilides are derived from tubercles, gumma, 
gummous infiltration, or sclerosing gumma. All of these, in contra- 
distinction to the ulcerative manifestations of the secondary period, 
are generally localized or regional. Five principal types are dis- 
tinguished: 



it 



V 



, 



FlG. 98. — A typical syphilitic ulceration on the thorax near the right axilla. 

1. Tvherculo-ulcerativb, also known as tuberculo-gummous xii}>hi- 
lides (Fig. ( .I7) consist of rather large dermic tubercles, from the 
size of a pea to that of a hazel-nut, of firm consistence, but almost 
invariably terminating in ulcerative disintegration. Usually grouped 
in clusters, crescents, etc., these ulcerations develop excentrically 
and become arranged in serpiginous patches or areas of a highly 
characteristic appearance. These areas are honeycombed scars, 
checkered with whitish, purplish or earthy hues; the polycyclic 
border presents, sometimes only on one side, rows of deep ulcera- 
tions, round or in their turn polycyclic and punched-out, discharg- 
ing a livid pus, or covered with thick, hard, adherent, sometimes 
ostreaceous crusts of a greenish-black color. The double polycyclic 
character of the patch and of its constituent ulcerations possesses 
marked diagnostic value. 

'_!. Syphilitic ulcerations which may be called atypical have a 
less characteristic appearance. As a rule it cannot be determined 
whether or not they have begun under the form of tubercles; at 



SUBACUTE ULCERATIONS 



287 



any rate, none are found at the circumference of the resulting lesion. 
This is usually a single ulceration, having the shape of an oval, a 
bean, an ear, etc., with regular margins describing fairly large 
curves, often with a moderately hard, raised border with an uneven 
rather shallow floor, sometimes cicatricial in the center (Fig. 98). 
Their distinct polycyclic contours, the indurated border, the 
parchment-like induration of their base, which, however, is not 
always easily demonstrable, the examination by biopsy, if necessary, 
serve to differentiate these tertiary ulcers from atypical tuberculous 
ulcers which will be discussed further on ; they are much less deeply 
evacuated than gummous ulcers; their shape is more regular and 
their progress is decidedly more rapid than that of an epithelioma. 





Fig. 99. — Syphilitic gummous 
ulceration. 



Fig. 100. — Syphilitic gummous in- 
filtration, deeply ulcerated in places. 
The woman from whom this photograph 
is derived suffered from lesions of the 
same kind on the thighs, the thorax and 
the neck. Cure in two months through 
calomel injections. 



3. Syphilitic gummous ulceration is a deeper lesion, with rounded 
or kidney-shaped contours, and loose, soft or edematous borders 
(Fig. 99). It results from the disintegration and evacuation of a 
hypodermic node. 



288 ULCERATIONS AND ULCERATIVE DERMATOSES 

-i. Ulcerated gummous infiltration is of very variable extent, 
depth and configuration. It may extend to the tendons, the vessels, 
the periosteum, even the hones, causing very serious mutilations 
(Fig. 100). 

,"). Sclero-gummous ulcerations arc those which originate in tertiary 
syphilitic, sclerotic or scar-tissue. They are observed especially 
on the tongue, though sometimes on the legs or in hypertrophic 
syphilomas. They result from a focal or a superficial necrosis, dry 
and caseous at first, later softening. Their abrupt onset, their 
irregular, sometimes angular form, the woody induration of their 
base, the slowness of their repair, are sufficiently characteristic. 

These different types of tertiary ulcerations are connected by 
numerous intermediate types. There is always a more or less dense 
and circumscribed specific infiltration of variable depth which 
has undergone partial necrosis and purulent disintegration. Their 
clinical evolution is very irregular, sometimes sluggish, sometimes 
rapid. Their own characteristics commonly suffice for a positive 
diagnosis, even in the absence of a history or other evidence of 
syphilis, which, however, should always be looked for. The Wasser- 
niann test and sometimes examination by biposy may be required. 
In some cases the mycoses must be kept in mind. These tertiary 
syphilides are usually very amenable to the influence of specific 
treatment . 

Tuberculosis.- The various types of ulcerations referable to 
tuberculosis differ in their appearance, their seat, their pathogenesis 
and also to a high degree in their virulence, but they are associated 
by connecting links. 

Tuberculous Ulcer. — Typical tuberculous ulcers possess peculiar 
features which as a rule permit them to be quite easily recognized. 
Their seat of predilection is on the lips or tongue, or at any point of 
the mouth or pharynx; frequently also about the circumference of 
the anus; rarely elsewhere. 

These ulcers are of ovoid, polycyclic or irregular shape, of an 
extent varying from a few millimeters to 1 or 2 cm., with wavy or 
ragged contours, perpendicular or detached borders, of a livid or 
purplish color, an uneven roughened granular floor, dotted with 
hemorrhagic points, often partly covered by grayish detritus. 
Tuberculous ulcers are almost invariably superficial, rather shallow. 

On its floor or at its periphery may be seen the yellow granules of 
Trelat, punctiform or of pin-head size, in greater or less number; 
or gray miliary ulcerations. 

The discharge is sanious and rarely profuse. The base is soft or 
.-lightly infiltrated. The regional glands are often enlarged. Always 
tender on pressure, tubercular ulcers may become distressingly 
painful when situated at points exposed to traction or friction. The 



SUBACUTE ULCERATIONS 



289 



course is very slow, extending over weeks and months, without 
showing a tendency to spontaneous cicatrization. 

The pathological anatomy of this ulcer is even more characteristic 
than its clinical appearance (Fig. 101). 

In cases of rapidly progressive phthisis, tuberculous ulcers of the 
mouth may occasionally be seen to originate and extend within a 
few days, constituting acute buccal phthisis. 









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Fig. 101. — -Histology of tuberculous ulcer of the tongue. Section from the margin 
of the ulcer. 6, detached margin of the ulcer; u, floor of the ulcer, showing a light 
fibrinous layer which covers a tissue infiltrated with pus; /, /, conglomerated or 
isolated tubercles; they are usually composed of one or several central giant cells 
a collection of clear epithelioid cells and an external zone of lymphocytes and plasmo- 
cytes. None of these tubercles is in direct contact with the ulceration ; g, a tubercle 
developed in a papilla; its enlargement or its confluence with other neighboring 
tubercles would give rise to a yellow granule of Trelat; m, striated muscle fibers of 
the tongue. X 40. 

Sometimes, the ulcer assumes the characteristics of the fissured 
variety being elongated in the diretion of a fold and resembling a 
rhagade with one irregularly ulcerated portion. This is observed 
at the commissures of the lips, their median furrow, on the lateral 
borders or at the tip of the tongue, at points irritated by carious 
teeth; or again in the radiating folds of the anus, whence the ulcer- 
ation may extend to the anal canal on the one hand and to the 
integument of a buttock on the other. 

The papillomatous ulcerative variety, resulting from a combination 
of the ulcer with a process analogous to that of papillomatous or 
19 



290 ULCERATIONS AXD ULCERATIVE DERMATOSES 

verrucous tuberculosis, is likewise not uncommon. The bare or 
keratotic papillomatous elevations develop on the congested and 
cyanotic floor at the border of the ulcer. This variety is seen 
especially on the lips and at the anus. 

The diagnosis of tuberculous ulcer is usually easy. Traumatic 
ulcerations heal rapidly when properly treated. Soft chancre is 
exceptional outside of the genito-anal region, has an abundant sup- 
puration, a rapid course and is auto-inoculable. Syphilitic ulcers 
have a more regular form and an indurated base; in difficult or 
doubtful cases, recourse may be had to serodiagnosis and the demon- 
stration of the bacillu.-. Asuspicionof ulcerated epithelioma makes 
the microscopical examination by biopsy imperative. 

Whenever the clinical features of the ulcer — although fairly char- 
acteristic — and the conditions under which it appears are not suffi- 
cient to remove all doubts, the diagnosis must always be confirmed 
by laboratory tots. The tissue-fragments obtained by scraping 
the floor, or better still from under the margins of the ulcer, contain 
bacilli; but it is necessary to scrape the tissues rather forcibly with 
a curette, bringing a little blood. Biopsy also must go rather deep. 
Inoculation into guinea-pigs may sometimes be necessary. 

Lupus Ulcerations. — The ulceration of a lesion of lupus, whether 
delayed or appearing at once on a lupus exedens, always presents 
certain definite features which have been pointed out by Du Castel. 

The borders are slanting, the adjoining tissue is purplish or 
brownish-yellow, tense, infiltrated, more or less transparent, soft, 
swollen, or covered with flabby proliferations. 

The shape of the ulcer is round or oval, somewhat regular. Its 
floor is slightly depressed, of a lardaceous gray, light red or brownish 
color, sometimes proliferating; it bleeds easily, is of spongy con- 
sistence and is readily lacerated. 

The base is the seat of a soft, non-plastic infiltration, more often 
movable than adherent to the subjacent tissues. 

The secretion is turbid, sanious, drying in thin adherent grayish- 
yellow crusts, which are deeply imbedded and rarely ostreaceous. 

Extension may be either superficial (lupus serpiginosus) , or deep 
I lupus terebrans), or finally in all directions (lupus vorax). 

Ulcerated Tuberculides. — Leaving out of consideration the minute 
punctiform ulcerations of the papulo-necrotic tuberculides, mention 
musl lie made of the sometimes extensive ulcers of erythema indur- 
(ituin. They constitute rather deep depressions, with variable 
borders, a grayish or mammillated and reddened floor and an exten- 
sively indurated base, all of which taken together with the purplish 
hue of the circumference and the seat of the lesion on the legs, invests 
them with a peculiar appearance (Fig. 102). 

Occasionally they coincide with scrofulo-tuberculous gummas. 



SUBACUTE ULCERATIONS 



291 



Atypical Tuberculous Ulcers. — Under this name I describe a clinical 
form which is not very uncommon and the diagnosis of which is 
always most baffling. These ulcers are usually met with in youthful 
individuals of the female sex who at the same time present either 
pulmonary lesions with a sluggish course, or cutaneous tuberculides. 




Fig. 102. — Large ulcerated tuberculide of the thigh, in a young woman suffering 
besides from scrofulo-tuberculous gummas and papulo-necrotic tuberculides. Cure in 
six weeks, under the influence of rest, good hygiene, injections of tuberculin and aseptic 
dressings. 



The ulcers are rounded, oval, or polycyclic, from the dimensions 
of a silver quarter to that of the palm of the hand, single or multiple, 
situated on any part of the integument. I have observed them on 
the shoulder, the neck, the chest, the groins, thighs, instep, etc. 
The irregularly outlined borders are often partly sloping, partly 
perpendicular or detached, of a dusky red or purplish color; the 
floor is grayish or bright red and proliferating; there are no yellow 
points, no lupus nodules; the base is slightly infiltrated and not 
indurated; they are absolutely painless. The course is extremely 
sluggish (Fig. 103). 

The diagnosis lies between ulcerative tertiary syphilide, con- 
genital syphilitic ulcer, abnormal tuberculous ulcer and ulcerated 
tuberculide. Laboratory investigations are required and yield 



292 ULCERATIONS AND ULCERATIVE DERMATOSES 

variable results. In the form of atypical tuberculous ulcer 
described by Man-el LeVy-Bruhl (These de Paris, L914), the his- 
tological lesions are clearly tubercular associated with vascular 
changes; the local tuberculin reaction and guinea-pig inoculation 
are positive. 

In clinically analogous eases I was unable to produce tubercular 
infection in guinea-pigs. The degree of virulence of these atypical 
ulcers is accordingly not uniform. They are apparently due to 
bacillary emboli rather than to external inoculations. The treat- 
ment of election is surgical extirpation; aside from this, a very 
favorable action is exerted by tuberculin therapy and radiotherapy, 
combined with scarifications. 




.luloso 



ilcer < >f the presternal region, co-incident with 
: i trc-< 1 seventeen years. Case of Levy-Bruhl. 



Leprosy. The ulcers 
course and pathogenesi: 
differentiated from tub 
are observed especially 



if leprosy have a variable appearance, 
First, the ulcerated lepromas must be 

•les or subcutaneous nodosities. They 
countries where leprosy is endemic, in 



severe cases, affecting neglected and badly cared-for individuals 
who drag along a miserable existence. The loss of substance results 
from partial disintegration of a bacillary infiltration, the remains 
of which are found at the circumference and at the base and becomes 
aggravated in consequence of vascular lesions and secondary infec- 
tions. These lepromatous ulcers lead to serious mutilations. 



SUBACUTE ULCERATIONS 293 

Leprous individuals are, on the other hand, exposed to trophic 
ulcers, especially in the nervous or mixed types. Consecutive to, 
or associated with pemphigus leprosa, these are very superficial at 
first but obstinate and soon become covered with a rupioid crust; 
later on, they spread but retain a regular configuration, perpen- 
dicular walls and a membranous floor. They are hyperesthetic or 
anesthetic. When there are no other symptoms besides anesthesia, 
the ulcers are characteristic of Lazarine leprosy. Bacilli may be 
found in these ulcers at the period of onset. 

Glanders. — The ulcerations which follow upon the abscesses or 
nodosities of chronic glanders, formerly called farcy, may present 
a fairly characteristic appearance, or on the contrary very closely 
simulate tuberculous, syphilitic or epitheliomatous ulcers 

The features peculiar to them are: their irregular shape, their 
livid purplish margins, undermined and ragged as if torn by the teeth 
of mice, their very irregular sinuous floor, the softness of their base, 
their painlessness; furthermore, the presence of fluctuating nodosities 
or small abscesses at their periphery. 

Mutilating glanders is apt to be situated in the center of the face, 
and causes considerable disfigurement and mutilation. The course 
is slow, irregular and progressive. The usual outcome is death. 

The diagnosis can be surmised under certain conditions, but is 
positively established only by means of cultures and animal inocu- 
lation. 

Dermatomycosis. — The ulcerations of sporotrichosis, blasto- 
mycosis, actinomycosis, and mycetoma (Chapter XXYIII) follow 
gummous nodosities, or sometimes after tuberculo-ulcerative and 
ecthymato-pustular dermic lesions. The pus contains the specific 
parasites, demonstrable on direct examination or by means of 
cultures. 

Phagedena. — Phagedenic ulcers are characterized by a very 
marked tendency to invade the neighboring tissues, superficially 
or deeply, continuously or with interruptions; or rather at intervals; 
they are accordingly acute in their course and chronic, in their 
duration. 

These ulcers take their start in various lesions, as if due to the 
effect of a complication or a malignant change. The initial lesion is 
very often a soft chancre, rarely a hard chancre and not infrequently 
a tertiary ulcerative syphilide or a congenital syphilide; sometimes 
it is a lesion of ecthyma or a patch of spontaneous gangrene. 

It goes without saying that not all extensive ulcerations must be 
grouped under the heading of phagedena — such as malignant 
secondary syphilides, tertiary syphilitic ulcers, tuberculous ulcers, 
cancerous ulcers, the ulcers of tropical diseases, etc., — but only 
those which assume a both prolonged and rapidly destructive course, 



2!)4 ULCERATIONS AND ULCERATIVE DERMATOSES 

not an ordinary attribute of their kind. The phagedenic nicer of 
hot countries will he discussed further on. 

Provided the necessary exclusions are carefully made, it will be 
seen that no matter what may he the original lesion, phagedenic 
nicer presents a rather uniform picture, to he presently described. 
Tin- observation has led the majority of writers to believe that 
phagedena is due to a superadded infection, a special bacterial 
agent, or a microbic association of particular virulence. Bacteriology 
having not as yet confirmed this theory, the conditions of the soil 
have been held responsible. It is true that phagedena sometimes 
attacks weakened or alcoholic subjects, but often also robust 
individuals; one is obliged to suspect in the latter a peculiar sus- 
ceptibility or a deficient resistance against certain infections agents. 
Although the majority of cases of phagedena occur in syphi- 
litica, they do not all have syphilis. Age and sex are apparently 
irrelevant. 

A phagedenic nicer is of very variable extent, according to the 
activity and duration of the process. In a few weeks or months, 
starting from the genital organs, it may have destroyed the larger 
part of the penis or the vulva, reached the thighs, the perineum and 
the buttocks; have invaded a considerable portion of the abdomen 
and the back; in the face it may have destroyed the nose, the lips, 
a cheek, etc. It involves practically always the entire thickness of 
the integument; when it burrows deeply, exposing the muscles, 
tendons, large bloodvessels, etc., it is described as terebrans: it is 
called serpiginous when it becomes partly cicatrized while elsewhere 
progressing. 

The configuration of the nicer is sometimes irregular, often poly- 
cyclic. Brocq pointed out an objective appearance which is most 
characteristic and which lie names geometrical phagedena, because 
its distinctly marked borders form perfect circles or ovals or parts of 
circles and ovals as if traced with a compass. 

The borders, surrounded by a red and infiltrated zone, from 4 
to 20 mm. wide, are perpendicular, sometimes undermined, with 
pockets of pns; in other eases sharply sloping. The floor, after it 
has heen cleansed of the thick and yellow, rather than sanions pus 
which covers it, appears raw, red and granular, or sprinkled with 
shreds of sphacelated tissues. The center is sometimes epidermi-zed 
and crusted. 

The invasion is rapid, fulminating in some eases; as a rule, its 
progress is much more pronounced at some points than at others. 
The corresponding glands are usually swollen and painful, but they 
rarely suppurate. Although sometimes painless, the nicer is more 
apt to he tender or even extremely painful on contact. 

Histological examination shows a severe phlegmonous process 



SUBACUTE ULCERATIONS 295 

with a tendency to rapid necrosis, but a not very extensive range 
(Dominici, Rubens-Duval and CI. Simon). 

Bacteriology shows nothing but staphylococci, often streptococci, 
but no specific agent. Fuso-spirillary organisms and the Bacillus 
ramosus of Villon are absent. The search for anaerobes will have 
to be kept up. 

Personally, in all cases which I have recently observed, the bacil- 
lus of Ducrey has been looked for without success; but I have 
always found the pus to be auto-inoculable on the patient's arm, 
producing a typical chancroid, only remarkable by a delayed develop- 
ment which may last from three to five days. [It is noteworthy 
that in these inoculated chancroids phagedenism does not develop]. 
This would lead me to assume that a large proportion of the most 
characteristic phagedenas, although evidently not all of them, are of 
chancroidal character. Caution is needed, for it is not in the nature 
of the chancre bacillus to remain indefinitely virulent in the same 
subject; furthermore, phagedena rarely gives rise to spontaneous 
auto-inoculations or chancrous bubos. 

Although the appearance of phagedena, as previously stated, is 
nearly always uniform whatever its origin, it is desirable to point 
out some peculiarities of the various formerly admitted types. 

Chancroidal phagedena is by far the most common. It originates 
in a soft chancre or in an open chancrous bubo and is therefore 
observed especially in the genital and inguinal regions. It does not 
possess the special features of chancrous ulcer, cracked or fissured 
borders, a yellowish worm-eaten floor, etc. I have seen it growing 
by true subdermal abscesses, opening at the surface or under the 
margins of the ulcer, where they form burrows and extensive puru- 
lent tracts. Chancrous phagedena, derived from a syphilitic chancre, 
is rare, unless one comprises incorrectly under this denomination 
the giant chancres and perforating chancres (terebrans) which may 
perforate the urethra in men, or the labia of the vulva, the lips, etc. 

Tertiary phagedena, referable to a tuberculo-gummous syphilide 
or a gumma, has its seat of predilection in the middle of the face or 
on the genital organs. It may cause enormous mutilations, with 
fulminating rapidity, destroying, for example, the cheek, the nose, 
the upper jaw, the turbinates, the roof of the palate, hollowing out 
an enormous cavity in the middle of the face; the destruction is no 
less considerable in the pharynx or about the genitals. On the trunk 
and the extremities, it has been noted that phagedena often exposes, 
without attacking them, the large bloodvessels and the nerves. 

The course of the phagedenic process varies in different cases, 
and even in the course of development of the same case. Par- 
tial cicatrization by itself alone is not a reassuring symptom, for 
extension may continue elsewhere or the cicatrix become eroded in 



296 ULCERATIONS AND ULCERATIVE DERMATOSES 

its turn. The total duration of the course of a phagedena usually 
extends over several years, up to four or five years, ten years or 
longer. The patients do not become cachectic, but the exquisite 
pain with each dressing causes them to become weakened and 
demoralized. Death from hemorrhage or septicemia rarely super- 
venes. 

Treatment.- In the presence of genuine phagedena, in a syphilitic 
patient, general specific treatment must not be considered as suffi- 
cient. Mercurial medication, even when energetic and supported 
by adjuvants and excellent hygiene, usually fails; intravenous 
injections of arsenobenzol are positively indicated at the present 
day, hut may prove insufficient. 

In view of the rapidity with which phagedena exerts its destruc- 
tive effects, local medication is imperative and must be very ener- 
getic from the start. The method of choice is the destruction of the 
infectious focus as a whole with superheated air, under general 
anesthesia. Extensive removal with the bistoury is likewise advo- 
cated, in the rare cases where it is practicable. When these measures 
are inapplicable, recourse must be had to cauterization with the 
thermocautery, zinc chloride, or tincture of iodin, which are of 
value only provided all the anfractuosities of the ulcer are reached. 
At the same time, or in the milder cases, repeated irrigation 
or washing with peroxide solution or hot potassium perman- 
ganate solutions. All kinds of antiseptic dressings and all varieties 
of powders have been tried. Brocq has obtained excellent results 
with a 10 per cent, collargol salve. [The Carrel-Oakin solution 
ought to give good results]. In these cases where the presence of 
chancroidal virus is probable or certain, no time should be lost with 
iodoform or silver nitrate, etc., but the heroic measures named above 
should be employed, notably hot air. Auto-inoculation on the arm, 
which experience has shown to be devoid of special danger, will 
serve to show if at a given point which may continue to appear 
suspicious after the general cauterization, virulent germs are still 
present and require renewed intervention. General tonic treatment 
and excellent hygiene, although insufficient by themselves, may 
favor the cicatrization after the ulcer has been transformed into a 
simple wound. 

ULCERS. 

Ulcus Cruris. I leer of the leg, also known as .simple ulcer or 
varicose ulcer, is a syndrome into the etiology of which a large 
number of conditions of various kinds enter. 

The seat of predilection of simple ulcer is on the lower half of the 
legs, somewhat more frequently on the left leg, at the inner aspect 
and above the malleolus. It is usually single, sometimes multiple, 



ULCERS 



297 



and in this case with a tendency to coalescence of the various ulcers ; 
its shape is oval, polylobar or polycyclic and its extent may reach 
15 and 20 cm. in diameter. Its floor is bright red or purplish, pro- 
liferating, oozing, or, in the absence of suitable care, covered with 
grayish detritus and sanious offensive pus. The borders are ad- 
herent, gently sloping or perpendicular, sometimes detached, thick- 
ened and callous (Fig. 104). The discharge is very variable, scanty 
and seropurulent when the patient remains in bed. 




Fig. 104. — Varicose ulcer of the leg, with callous margins. 



Sensibility is usually diminished and delayed on the ulcer and in 
its circumference, especially thermic sensibility, although painful 
and tactile perception are also lessened. 

The periphery of the ulcer may be erythematous in a more or less 
extensive area, but otherwise normal; this is rare. As a rule, the 
neighboring and adjacent tissues are the seat of various changes, 
some depending on causes which have prepared the soil of the ulcer, 
others on secondary infections, unclean dressings, etc. 

The complications consist of: Varicosities, which will be referred 
to again presently; varicose eczema, often circumscribed, which 



298 ULCERATIONS AND ULCERATIVE DERMATOSES 

may be dry, scaly, cracked, crusted, oozing, rubrum, impetiginous, 
etc., pigmentation of clay color, resulting from repeated intradermic 
hemorrhages; lymphangitis, more or less acute, or mild and recur- 
rent; edema, sometimes soft and plastic, or more frequently non- 
depressible, elephantiasti< — a hypertrophic callous state, or on the 
contrary a sclerotic atrophy. These last named lesions are entitled 
to a moment's attention. 

Leu ulcer in the callous state has thickened, infiltrated, prominent 
borders, of cartilaginous or woody hardness; they slope rapidly in 
both directions and particularly steeply on the side of the loss of 
substance, which is often pale and covered with grayish detritus. 
The induration extends below the ulcer, and more or less far on the 
leg and foot; it involves not only the skin, but all the subjacent 
tissues, down to the bones. 

These callous ulcers are sluggish, obstinate, extensive and not 
readily curable. 

The fibrous induration may terminate in hypertrophy, in a second- 
ary elephantiastic state, determined by inflammatory lesions of the 
lymphatics, bloodvessels and nerves. The bulk of the limb may 
become enormous and present deformities — which will be discussed 
under the heading of elephantiasis — with a supramalleolar cushion 
and swelling of the dorsum of the foot and the toes. The surface 
is smooth or hyperkeratotic, or more frequently papillomatous and 
verrucous. 

In other cases the skin in the vicinity of the ulcer is in a state of 
diffuse or reticulated sclerotic atrophy; under these conditions it is 
thickened, smooth, tense, cannot be folded and presents a mottled, 
white, brown or purplish color. It is common for this dermato- 
sclerosis to precede the formation of the ulcer. 

The inguinal glands are often enlarged, the tendon reflexes of the 
limb may be absent; there is sometimes a slight muscular atrophy. 

The nails of the foot are usually discolored, opaque, stratified, or 
even in a condition of pronounced onychogryphosis. It is not rare 
t'oi- the hairy system to be hypertrophied and for hyperidrosis to 
exist. These accessory lesions are often present on both sides, 
although the leg ulcer is unilateral in the majority of the eases. 

Varicosities, which almost invariably accompany ulcer of the leg 
and exist on both lower limbs, rarely form large subcutaneous 
strands. The latter do not predispose to ulcer so much as the deep 
varicosities, which are not very visible and are not perceived unless 
the patient stands up, or by very careful palpation. They give rise, 
prior to the formation of the ulcer, to pigmentations in patches, 
reticulated, or in the form of an areola around a cicatrix; to telan- 
giectasis; predispose to edema and eczema, and cause cramps, 
itching and a sensation of heaviness of the limb. 



ULCERS 299 

The ulcer begins in a variable manner; as the result of a wound, 
an ecchymosis, a small traumatic scar, a venous rupture, a small 
focus of phlebitis, an eczematous lesion, an impetigo or ecthyma 
pustule — all these lesions, instead of rapidly healing as they would 
on a well-nourished soil — persisting, becoming infected, deepening 
and enlarging under the crust which covers them. 

It is exceptional for leg ulcer to begin as a plaque of spontaneous 
gangrene, although I have several times observed this occurrence. 

Etiology. — Ulcer of the leg is observed especially between the 
ages of thirty-five and sixty years, slightly oftener in the male sex, 
in fatiguing occupations which require the erect position; in women 
who have had numerous pregnancies and in the poorer classes. 
The patients are, as a rule, atheromatous; sometimes polysclerotic, 
especially with renal sclerosis. 

To the role played by deep varicosities as an etiological factor, 
established by Verneuil, has been added that of neuritis, deemed by 
Quenu to be itself of varicose origin; furthermore, that of arteritis. 

It is readily understood that these general and local conditions 
impede the healing of the small above-enumerated lesions. This is 
not all, however. On this undernourished and poorly resistant soil, 
microbic infections are grafted and come to play the decisive part 
in the ulcerative process, in the recurrent lymphangitides, and in 
their sequel, dermatosclerosis. 

Among the innumerable microorganisms of all kinds which 
flourish on these ulcers, the principal pathogenic agent seems to be 
most commonly the streptococcus. Leg ulcer has been described as 
"a chronic streptococcic chancre" (Sabouraud). 

This local streptococcia is indefinitely prolonged, sometimes 
latent during long periods of time; not infrequently, the presence 
of the Bacillus pyocyaneus is likewise demonstrable. 

Still other parasites when favored by special local conditions may 
undoubtedly give rise to a symptom-complex identical with that of 
simple ulcer. 

It has long been noted that leg ulcers of typical appearance, in 
admittedly syphilitic individuals as well as in cases of undetected 
syphilis, will heal under mercurial medication. More recently, 
objectively similar cases have been recognized as tuberculous, 
through experimental inoculation. It is not known, however, to 
what extent these specific infections are involved. 

Diagnosis. — The essential point consists, not in the recognition of 
the syndrome of leg ulcer, but in determining what part is referable 
to general and local predisposition as well as to the ordinary or 
specific infections. 

Simple ecthyma is distinguished by the multiplicity of its lesions, 
their acute inflammatory character and their course. 



300 ULCERATIONS AND ULCERATIVE DERMATOSES 

Ulcerative syphUides and syphilitic gummas are usually multiple 
and bilateral, preferably situated on the external aspect of the legs. 
The former are often grouped in ares of circles. Gummas begin as 
a nodosity and, after ulceration has occurred, are characterized by 
their rounded shape and undermined borders. 

So-called tuberculous ulcer* follow upon bony lesions or scrofulo- 
tuberculous gummas, or upon fungoid or lupoid tuberculosis, which 
are recognized by their special features. 

Ulcerative erythema induratum of Hutchinson's type is met with 
only in youthful persons. 

As stated above, these affections may lose their specific marks in 
a varicose and sclerotic territory. 

Treatment. — This is medical or surgical. Innumerable methods 
and remedies have been advocated. In the first place, it is most 
essentia] to insist upon rest in the recumbent position, with the foot 
slightly elevated. The inflammation should be soothed and the 
ulcer cleansed by prolonged local baths, application of powders, 
aseptic or weakly antiseptic cytoplastic moist dressings. Strong 
antiseptics being rather injurious. [Liq. aluminii acetatis, one part 
to ten of water is one of the best of these moist dressings.] 

After improvement has begun and the inflammation subsides, the 
formation of healthy granulations must be stimulated by means of 
dry dressings with inert or weakly stimulating powders, aristol, 
iodoform, iron subearbonate, collargol, etc., the old styrax oint- 
ment, which has lost nothing of its value as a stimulant, as well as 
balsam of rem. 

Modern procedures may also be resorted to, such as light baths, 
radiotherapy, high-frequency currents, hot air; they sometimes 
exert a highly favorable action. 

Imbricated strips of adhesive plaster, or better still, dressings with 
cotton or zinc glycerin-gelatin, which is valuable in these cases, or 
with elastic bands, may permit the patient's attending to some of 
his work. It is advisable not to change the dressings too frequently 
in leg ulcers that are healing. 

The remarkably rapid healing of certain leg ulcers of ordinary 
appearance under the influence of mercurials, notably calomel 
injections, led to the adoption of the general rule always to give 
mercury a trial. At the present day, serodiagnosis should be called 
upon in all such cases and its indications be followed. 

Surgical procedures, such as circumvallation, radiating incisions, 
etc., are merely mentioned by name in this connection, but it should 
be kept in mind that carefully and judiciously applied grafts may 
greatly shorten the time of cicatrization and furnish a better scar. 
In a few incurable cases of callous ulcer surrounding the entire leg, 
amputation has proved unavoidable. 



ULCERS 301 

After a leg ulcer has healed all efforts are in order to guard against 
recurrence. Roller bandages, elastic stockings, massage, local and 
general hygiene, may act efficiently in this connection. Electro- 
therapy in the form of ionization, combined with radiotherapy, is 
very serviceable for the control of dermatosclerosis. 

Phagedenic Ulcers of Tropical Countries. — In the hot and moist 
climates of the tropical and subtropical zone of both hemispheres, 
ulcers of as yet undetermined character have been observed, which 
are called tropical ulcer, or according to the regions where they 
occur, Annamite ulcers, Mozambique ulcer, malgache, etc. 

It is more than probable that this syndrome comprises altogether 
dissimilar types and has often been made to include ulcerative 
syphilides, chancrous phagedenas, leishmaniosis, varicose ulcers, 
etc. Tropical ulcer is usually situated in the lower third of the legs, 
or on the dorsum of the foot, very rarely on the hands, exceptionally 
elsewhere. It begins as a papulopustule which becomes gangrenous 
and spreads. It has rounded or oval contours, flat, unthickened 
borders and often a concave or funnel-shaped center. 

An atonic form has been described ; the sometimes very extensive 
loss of substance has a grayish, diphtheroid or sanious floor and a 
serpiginous outline; repair is delayed a long time and recurrences 
are common, even after several years. 

The rapid, phagedenic or gangrenous form is extensive or per- 
forating and advances in acute attacks, sometimes associated with 
fever; the ulcer is lined with soft fetid masses; it makes deep bur- 
rows, opens tendon sheaths and joints, exposes the bones, becomes 
complicated by lymphangitis or neuritis and gives rise to mutilations 
and fault)' cicatrices. After a certain length of time, it may become 
atonic. 

In both forms, a sensation of heat and sometimes intolerable pains 
are present. There is practically no tendency to spontaneous cure, 
except when the patient moves to a different climate. 

Tropical ulcer is observed in wretched and exhausted individuals, 
weakened by alcohol, malaria, etc., especially in those who work 
with bare feet in water, as in rice plantations, etc. 

The starting-point is an excoriation or a wound, the bite of a 
leech, or mosquito, a pustule of ecthyma, an ulcerative syphilide; 
briefly, any entrance for infectious microorganisms. 

Tropical ulcer, although only slightly contagious, is inoculable 
and auto-inoculable; animals are not susceptible. 

A variety of bacilli have been described. Le Dantec and others 
had observed a matting of bacilli; Vincent (1905) showed it to be 
caused by a fusospirillary association (Spirocheta schaudinni, Prow- 
azek 1907), thereby proving its identity with hospital gangrene 
and ulcerative membranous stomatitis. 



302 



ULCER A TIONS A XD ULCER A 77 \ E DER MA TOSES 



Treatment con>ists in first cleansing the ulcer by means of 
washing and suitable dressings, dry or moist, sometimes assisted 
bj curettage. After it has been cleansed, washing with a zinc 
chloride solution, the application of calcium chloride as a powder or 
of protargol ointment of ."> to 20 per cent. (Castellani) or powdered 
arsenobenzol is in order, avoiding caustic agents and bland powders. 
Intravenous injections of arsenobenzol, although sometimes remark- 
ably effective, may fail unless combined with good local treatment. 
In all cases, absolute resl is imperative and the general condition 
musl be improved by appropriate measures. 



Fig. 10."). — Malum perfori 
itated Mm]. mat ii 




i firsl attack \\1 ich I ad 
f the first metatarsal. 



From the prophylactic viewpoint, it i> well to remember that in 
hot eoi nitric-, all wounds including the most trifling abrasions*should 

l»c carefully Matched and dressed. 

Malum Perforans. This name has been given to ulcers of small 
dimensions and very slow course, apparently connected with a 
trophic disturbance. They are observed in adults and aged indi- 
viduals, oftener in the male sex, especially in the course of tabes, 
sometimes diabetes, syringomyelia, leprosy, polyneuritis, arterio- 
sclerosis ami sometimes without a demonstrable cause. 



ULCERATIONS OF MUCOUS MEMBRANES 303 

Malum perforans plantaris, studied by Nelaton, has its seat of 
predilection under the head of the first or fifth metatarsal, or at the 
heel, or on any other point of the foot exposed to pressure (Fig. 105). 
There are sometimes several ulcers and both feet may be affected. 

The disease usually begins as a painful corn, a rounded hyper- 
keratosis on which blisters are repeatedly formed, or as a small 
crust. Before long, under the horny covering or under the crust, 
a rounded ulcer is found, with a proliferating or atonic floor, with 
perpendicular walls surrounded by hyperkeratosis. It burrows 
more or less deeply, and may reach the tendons, joints and bones and 
the latter when examined by .r-rays are often found to be altered. 

This lesion is painful on strong pressure, but often entirely 
anesthetic to needle-pricks in a variable radius. 

Cases of mal. perforans affecting the fingers (malum perforans 
digitalis), the back of the foot, the nose or mouth, which may be 
encountered in the course of tabes, as well as mal. perforans of 
amputation-stumps, are very rare. They consist in losses of sub- 
stance resembling traumatic abrasions, but occurring spontaneously, 
painless and anesthetic, often symmetrical, without any inflam- 
matory reaction and indefinitely persistent. Buccal mal. perforans 
is often preceded or accompanied by a fall of teeth and frequently 
gives rise to losses of bony substance through absorption or seques- 
tration. 

The treatment of mal. perforans plantaris requires rest; the horny 
masses should be scraped off after moist dressings or a salicylic 
acid plaster has been applied, followed by curettage or cauterization 
of the ulcer. The wound is dressed with substances favoring 
cicatrization. 

High frequency currents have seemed to me to be very efficient. 
In tabetic cases, healing is not infrequently obtained by intravenous 
injections of arsenobenzol. In order to guard against recurrences, 
which are always to be feared, it is advisable to protect the region 
against all pressure by means of appropriate dressings or special 
foot-gear. 

In the grave cases associated with suppuration and opening of 
joints or bony necrosis, partial amputations are sometimes unavoid- 
able. 

ULCERATIONS OF MUCOUS MEMBRANES. 

Although a comparison of the ulcerations of the various mucosa 
would be extremely interesting from the diagnostic point of view, 
the subject is too large for full presentation. I shall therefore discuss 
only the buccal mucosa (excluding the isthmus of the pharynx and 
consequently the anginas) and the genital mucosa?. On the other 
hand, the term "ulceration" will be used in its widest and most 



304 ULCERATIONS AX J) ULCERATIVE DERMATOSES 

comprehensive sense, so as to cover the most superficial epithelial 
abrasions up to the deepest ulcers. It must be conceded, however, 
that completeness is almost impossible in a subject of this kind. 

Buccal Mucosa. — In considering an ulceration of the mouth, all 
its features must be carefully noted by the physician, but with 
special attention to the following points: depth, condition of the 
surface, configuration, base, number, site, course. Needless to say, 
the diagnosis will usually be greatly helped by the general exami- 
nation of the patient. 

1 . Dry Erosions or Depapillated Plaques of the Tongue. — When 
these are persistent and not dependent upon a stomatitis, an acute 
infectious disease or a gastric disorder, they should suggest syphilitic 
smooth plaques, sclerotic glossitis, mild leukoplakia or glossitis 
inarginata. There are still other smooth plaques the origin of 
which is not always demonstrable. 

2. Moist and Diphtheroid Erosions. — All vesicles or bullae of 
mucous membranes are very rapidly transformed through macera- 
tion and loss of the raised epidermic layer into erosions which are 
frequently covered with a pseudomembrane. 

Buccal herpes is characterized by round microcyclic erosions, 
often grouped or confluent, rather painful, not very persistent. 
This herpes is recurrent in certain individuals. 

Buccal zona, which is extremely rare, is said to be unilateral and 
non-recurrent. 

Artificial bullae, resulting from burns, produced by a cigar, for 
example, are often of irregular shape and obvious localization. 

Hydroa and Duhring's disease are accompanied, in about one- 
half of the cases, by buccal lesions on the inner surface of the 
checks, the posterior surface of the lips, the palate, sometimes on 
the tongue or on the isthmus of the throat; in the form of rounded 
or superficially confluent bright red erosions partly covered by a 
membranous or diphtheroid layer and extremely painful. The 
coexistence of the cutaneous eruption reveals their true character. 

Chronic pemphigus has, on the contrary, a nearly constant and 
often primary buccal localization; it may remain the sole mani- 
festation for many weeks. 

In the few cases which have come under my observation, the 
pillars of the fauces, the pharynx, the cheeks and, later on, the lips 
and the borders of the tongue presented grayish or sanious, friable 
or adherent false membranes, covering partially ulcerative and 
oozing erosions, of irregular form and slowly progressive course. 
Objectively, the condition suggested diphtheria, Vincent's stoma- 
titis, a medicinal stomatitis, or even syphilides. The pains were 
intolerable, the odor was offensive, the glands were enlarged; the 
general condition was seriously affected, with slight fever, but very 



ULCERATIONS OF MUCOUS MEMBRANES 305 

rapid emaciation. The diagnosis, rendered probable by these con- 
ditions and by the presence of a slight bullous elevation at the 
margin of the erosions, was confirmed by the appearance of blebs 
in the genital region and on the fingers. The gravity of this fearful 
disease is well known. 

Syphilitic mucous patches are the most frequent buccal erosions 
and ulcerations and those which it is most important to know. The 
general description and that of the principal varieties are given else- 
where in this book (p. 620). It must be kept in mind that it is not 
justifiable to base the diagnosis of syphilis simply on the demon- 
stration of lesions presenting the appearance of mucous patches, 
for they are not characteristic in themselves (A. Fournier); the 
coincidence of other manifestations with their special chronology 
is required or the demonstration of the Spirocheta pallida, a posi- 
tive Wassermann reaction, generalized glandular enlargements, 
etc. 

Syphilitic chancre is ordinarily erosive on the tongue. It is seen 
at the extreme tip of the organ, in the form of a fissured erosion; or on 
the dorsal aspect of the anterior third, in the form of a lenticular 
or oval, pink or sometimes grayish, single and painless eroded spot. 
Very careful palpation reveals a parchment-like induration at its 
base; the corresponding glands always assume a disproportionate 
enlargement as compared to the apparent importance of the lesion ; 
they are non-inflammatory and painless; occasionally, the glands 
are the first to attract attention and point to the initial lesion. On 
the gums the chancre is likewise merely an erosion, frequently 
semicircular. 

Buccal diphtheria is rarely primary, being generally secondary 
to diphtheritic angina. It consists of irregular pseudomembranous 
adherent patches, located on the lips and on the inner surface of 
the cheeks. The Loefner bacillus is found, either in pure culture or 
in varied associations. 

Diphtheroid stomatitis is of frequent occurrence in children; 
the false membrane here is less coherent; it is apparently often 
due to pyococci. The most distinctive form is impetigo buccalis 
(impetiginous stomatitis of Sevestre and Gaston), the features of 
which have been described elsewhere. 

Thrush (soor, muguet) is not an ulcerative lesion, but might be 
confused with a diphtheroid erosion. It presents the appearance 
of a pure white or creamy adherent layer on an erythematous base ; 
when it is detached, the mucosa is seen to bleed. Thrush is observed 
in cachectic individuals and in little children suffering from digestive 
disturbances. It occurs on the tongue, the cheeks, the isthmus, in 
the form of very small elevations which subsequently become con- 
fluent in ragged irregular patches. On inspection under the micro- 
20 



306 ULCERATIONS AND ULCERATIVE DERMATOSES 

scope, the coating is shown to be made up of epithelial debris and 
very abundant filaments of endomyces albicans. 

3. Ulcerations. In whooping-cough (pertussis) of children, an 
ulceration of the frenuni of the tongue is observed, caused by its 
rubbing against the teeth and assisting the diagnosis by its location. 
Other simple ulcers, especially of traumatic origin, due to bites 
(as in epileptics) or to friction of the mucosa, are encountered at 
any age on the border of the tongue, or sometimes on the inner 
surface of the cheeks or the lips, notably at points which are in 
contact with some roughening of the teeth, due to dental caries, etc. 
These ulcerations are deep, of irregular shape with an edematous or 
sometimes indurated base, painful and usually without glandular 
involvement. They heal spontaneously after the removal of the 
offending tooth or roughness and disinfection of peridental foci of 
suppuration. 

Common a phi ha- are small, punctiform, or at most lenticular 
yellowish ulcerations, perfectly round or oval, following upon a 
grayish vesicle and surrounded by a characteristic carmine-red 
narrow border; they give rise to a very painful burning sensation. 
They are seen at all ages, always in very small numbers, but these 
aphthae may come and go for a long time in dyspeptic and nervous 
individuals following errors in diet, overexertion, or irritative local 
causes in the mouth. The co-existence of herpes is not uncommon. 
Inflammatory complications are rare. 

Common aphthae are certainly in no way related to aphthous 
fever, a contagious disease of bovine origin, apparently trans- 
missible to man through cows' milk [foot and mouth disease]. 
According to certain writers, this gives rise to an abundant erup- 
tion of aphthae in the mouth, together with serious general manifes- 
festations; but this is not an established fact. 

The ulcero-membranous stomatitis of Rilliet and Barthez and 
of Bergeron, which is now considered as identical with Vincent's 
angina and stomatitis, is due to mixed infection with the fusiform 
bacillus and spirilla; it is easy to demonstrate these parasites, 
which are seen in large numbers and often in pure cultures on 
smears of the exudate stained with dilute Ziehl's solution or car- 
bolized thionin. 

\ incent's stomatitis is observed particularly in children and 
youthful individuals, especially in weakened or exhausted persons, 
sometimes in almost epidemical form in crowded places, asylums, 
barracks, etc. |lt was quite common among the soldiers in the 
( rreal War and was known as trench mouth. | The onset is followed 
Immediately, or after a few days of fever, malaise, and local distress, 
by salivation, an offensive breath and pain. 

Inspection of the mouth shows swollen and ulcerated gums; on the 



ULCERATIONS OF MUCOUS MEMBRANES 307 

cheeks, especially in the vicinity of the last lower molar tooth, 
then on the entire inner surface of the cheeks and sometimes of 
the lower lip, rounded ulcerations, or a sinuous ulcerated band, 
make their appearance. The lesions often invade the sides of 
the tongue, sometimes the palate and the velum or the tonsils; 
in some cases they remain unilateral or predominate on one side. 

The following are some of their most essential features: the 
floor of the ulcers is grayish or the color of wine-dregs, usually 
masked by pultaceous, sanious, or even gangrenous detritus; per- 
pendicular borders; a non-indurated base; the teeth are often 
bared through erosion of the alveolar margin ; severe pain is present ; 
mastication is impossible ; there is profuse salivation and a peculiar 
disgusting odor. 

The submaxillary glands are enlarged and painful; the expression 
of the face is drawn and pale; there is well-marked anorexia; a 
slight fever may be present. 

When left untreated, the affection may last during several weeks 
or even months; by proper care, it can be cured in eight to fifteen 
days. The prognosis is on the whole favorable. 

Syphilitic chancre of the mouth, in contradistinction to tonsillar 
chancre, is very rarely ulcerative. 

Ulcerative secondary syphilides are observed in the ordinary 
forms of the disease as well as in precocious malignant syphilis and 
are characterized by their sharp outline circular form and by the 
depth of the lesion; they develop rapidly. 

The ulcerative gummas of the tongue and the sclero-gummous 
idcerations have been discussed elsewhere. 

The ulcerations of leukoplakia deserve special mention. In the 
patches on 1he tongue, as well as on the cheeks and the lips, there 
are frequently encountered, not only more or less persistent fissures, 
but also very peculiar chronic ulcerations which do not seem to 
have attracted the attention of authors. I have repeatedly called 
attention to the characteristics of these leukoplasic ulcers. 

Their shape is irregular, often angular; their floor, of a bright red 
color, smooth or finely mammillated, is frequently raised on a 
plane up to the level of the borders, from which it is separated by 
a deep furrow cut out as if with a knife and brought into view by 
unfolding it. 

Besides being a source of annoyance, obstinate to treatment and 
frequently recurrent, these ulcers are furthermore alarming because 
they give rise to the dread of epithelioma; it is reassuring that their 
base is not more indurated than that of the neighboring sclerotic 
surfaces. In my opinion they are due to a local nutritional dis- 
turbance of the mucosa, referable to the underlying sclerosis and 
arteritis. 



308 ULCERATIONS AND ULCERATIVE DERMATOSES 

In order to cure them, recourse must be had to calomel injections, 
intravenous injections of arsenobenzol, or to local mercurial injec- 
tions of weak concentration. Putting the teeth in good condition 
and proper buccal hygiene are indispensable. I regard it as inad- 
visable to irritate these lesions by caustic agents, but have often 
had good results from the employment of radium or .r-rays. 

Trophic ulcer, malum perforans of the mouth, has been observed, 
especially in tabetic patients, on the alveolar margin and the bony 



Tuberculous ulcer has already been described. I repeat that the 
tongue and the lips are among its seats of election. 

I shall not dwell upon the buccal ulcerations of very variegated 
appearance which occasionally occur in the stomatitides of uremia 
and diabetes, in scurvy and other severe infectious diseases or con- 
ditions leading to cachexia. 

Mercurial stomatitis is probably merely a special instance of 
Vincent's spirillary stomatitis. In its milder forms, it is limited 
to superficial irregular ulcerations, covered with a white mass, 
situated at the neck of the last molar tooth and its immediate 
neighborhood, at the neck of the lower incisors and sometimes on 
the borders of the tongue. They are accompanied by profuse 
salivation, a diffuse doughy exudate and a characteristic fetid odor. 
In the severe forms, however, deep gangrenous ulcerations have 
been noted, involving the checks, the gums, or even the bones and 
sometimes true gangrene of the tongue. 

Noma, or buccal gangrene, was described in former times as 
rather frequent in children between two and four years of age, 
especially as a sequel of measles or typhoid fever, sometimes occur- 
ring in epidemic form. 

Noma in children was said to begin as a livid swelling of the 
cheek; the mucous surface presents one or several blisters, covering 
livid then grayish sloughs; their fall leaves an ulceration which 
rapidly spreads and burrows, with ragged margins and a sanious, 
irregular, horribly offensive floor, sometimes perforating the cheek. 
The teeth fall out and the bones become necrotic. Death supervenes 
in four-fifths of the cases, in eight to fifteen days. 

The condition in all probability represented an ulcero-membran- 
ous stomatitis, due like hospital gangrene to a fuso-spirillary infec- 
tion. The very grave eases to which the above description is 
applicable have fortunately become extremely rare. 

In the tropics, among half-famished and improvident natives, 
cases of extensive gangrene of the lips and cheeks are observed, 
suggestive of noma and perhaps referable to the same etiology, 
but more probably the result of phagedena of various kinds. 



ULCERATIONS OF MUCOUS MEMBRANES 309 

4. Ulcerative Neoplasms. — In the cases of tuberculo-ulcerative 
syphilide of the buccal cavity, or in the less common cases of ulcer- 
ated lupus of the buccal mucosa, it is readily seen that the ulcera- 
tions are not primary, but develop on a neoplastic patch having the 
features described above. They are generally multiple, rounded, 
perpendicular, with a relatively hard base in case of syphilis; 
irregular, less deep, with soft borders, in case of lupus. 

Epithelioma of the buccal cavity is, in the great majority of the 
cases, of the lobulated types. I have, however, seen numerous 
instances of tubular [basal-celled] epithelioma. 

In the great majority of cases, epithelioma is situated on the 
tongue or on the lips, sometimes on the cheeks, the pharynx, the 
palate, the gums, the floor of the mouth. It begins under the 
papillary form, or as a fissure, as I have pointed out in connection 
with leukoplakia, and also as a discoid elevation from the start. 
It becomes eroded very soon and then excavated by an ulceration. 

The characteristics of epitheliomatous ulcer are as follows: 
Almost invariably irregular shape; very uneven, proliferating, 
sanious, readily bleeding floor, sometimes interspersed with small 
yellowish or gray masses; raised, swollen or overhanging borders in 
lobulated epithelioma, perpendicular borders in the tubular form; 
the base is always indurated, forming the tumor. Glandular 
enlargement occurs early in lobular epithelioma and determines 
an unfavorable prognosis; it is absent or very much delayed in the 
tubular variety. 

Actinomycotic ulcer of the mucosa has the same characteristics 
as in the skin. Yellow granules can be extracted from it. The 
reader is referred to Chapters XXVIII and XXIX for the buccal 
ulcerations of the sporotrichoses, leishmaniosis, etc. 

Other tumors, notably the sarcoma known as epulis, or even 
benign neoplasms, may become accidentally ulcerated. 

Treatment of Buccal Ulcerations. — In a general way, much can be 
accomplished by scrupulous hygiene for the prevention of ulcera- 
tions of the buccal mucosa. Prophylactic treatment consists in 
proper care of the teeth and gums; the mechanical removal of 
tartar, cleansing and filling of carious cavities, extraction of stumps, 
cauterization of fungoid or soft gums and adjustment of prosthetic 
apparatus, should be left to the dentist. The results achieved 
must be maintained by regular brushing with a soapy powder or 
paste or any good dentifrice. 

These measures are positively required in syphilitics, from the 
beginning of mercurial treatment, in patients recovering from severe 
infections, in persons predisposed to herpes, aphtha?, etc. In 
addition there should be abstinence from tobacco, alcoholic bev- 
erages and irritating food. 



310 ulcerations and Ulcerative dermatoses 

As to curative treatment, only brief suggestions can here be 
offered. Erosions, opaline mucous patches and aphthae are bene- 
fited by superficial silver nitrate cauterizations every second or 
third day; irrigations with dilute peroxide water or potassium 
chlorate. Soothing mouth washes are sufficient in cases of acute 
irritation. Mechanical cleansing with a wisp of cotton wet with 
alkaline or horated solution will suffice in thrush. 

The ulcerations of ulcero-membranous stomatitis are treated with 
mouth-baths of dilute Labarraque's solution, 1 to 20; cleansing with 
a small stick wrapped in cotton, followed by touching with silver 
nitrate; with powdered arsenobenzol, calcium chloride in substance, 
powdered methylene-blue or iodine tincture. Internally, sodium 
chlorate, grams 2 per diem, is recommended. Intravenous injec- 
tions of arsenobenzol are efficient only when combined with 
proper local treatment. [It is the method of choice in Vincent's 
infection.] It is highly advantageous to apply to syphilitic ulcers, 
together with the indispensable general treatment, the various 
topical agents enumerated above. The treatments suitable for 
the other cases have been discussed elsewhere. 

Genital Mucosae. — The majority of the erosive or ulcerative 
affections occurring in the mouth may also be encountered on the 
genital mucosa? or semimucosse of both sexes. 

This is especially true of herpes, which is common in this location; 
of syphilitic manifestations of all kinds and of hydroa; on the other 
hand, aphthae, impetigo, thrush and diphtheria are rare. Again, 
localizations of various dermatoses are here met with, which do 
not occur in the mouth, such as eczema, psoriasis, eczematides, 
scabies and, furthermore, a few special erosions and ulcerations. 

Traumatic excoriations due to coitus, scratching with the finger- 
nails, rape, etc., often have a characteristic irregular or fissured 
form; unless complicated by a superadded affection they heal with 
remarkable rapidity. 

Soft chancre has been sufficiently emphasized and does not require 
further discussion. 

Gonorrhea gives rise, in men, to a more or less acute diffuse 
balanoposthitis, sometimes with phimosis and ordinary or follicular 
erosions at the base of the glans and in the sulcus. Gangrene 
of the prepuce in these cases is very rare. 

In women, gonococcal vulvitis may be accompanied by small 
para-urethral follicular ulcerations, by canaliculitis , namely inflam- 
mation, sometimes ulcerative, of the excretory duct of Bartholin's 
gland, sufficiently characterized by its seat; finally, by gonococcal 
erosions of a dusky red, granular surface, distinct or jagged margins, 
localized especially outside of the caruncuhe myrtiformes. Being 
frequent and very persistent, these lesions may at the first glance 



ULCERATIONS OF MUCOUS MEMBRANES 311 

betray the existence of gonorrhea, which the patient is endeavoring 
to conceal. 

Diabetes gives rise not only to erythematous, eczematous, etc., 
balanoposthitis and vulvitis, but also to fissures and ulcerations 
of very variable aspect, syphiloid in appearance, and even to 
gangrenes. 

Circinate erosive balanoposthitis manifests itself in the form of 
extensive polycyclic, superficially erosive lesions bordered by a 
narrow white margin. This affection, attributed to spirilla by 
Berdal and Bataille, was recognized by Queyrat as a localization 
of the fuso-spirillary symbiosis which also causes Vincent's stoma- 
titis. An analogous affection may be met with in women. In 
neglected cases, circinate balanitis lasts several weeks and is often 
recurrent. It is very easily cured by cleanliness and painting with 
a 1 to 30 solution of silver nitrate. 

Syphilitic chancre, the different varieties of secondary syphilides 
or mucous patches, and the tertiary syphilides of the genitals have 
served for the descriptions of the manifestations which I have already 
given. 

Tuberculosis may manifest itself in the same regions, although 
this is very rare, as tuberculous ulcer, resulting from a contagion 
or auto-inoculation and as ulcerated lupus, which is still more 
rare. 

Under the name of esthiomene, introduced by Huguier in 1848, a 
rare syndrome is still occasionally described, which is character- 
ized by a chronic ulceration of the vulva associated with elephan- 
tiasis. The more or less deep and often painless ulcer is situated 
at any point of the vulva, preferably at the entrance of the vagina. 
The sometimes enormous hypertrophy involves the labia minora, 
the clitoris, the labia majora, the perineal region, etc. 

It is more than likely that the nature of the ulcer is very different 
in different cases, so that there may be tuberculous or lupus ulcers 
(Bernutz, Ficquet), soft chancres of low virulence (Jacobi), ulcera- 
tive tertiary syphilides, analogous with anorectal syphiloma, or even 
epitheliomas, which as a result of local conditions, notably a lack 
of cleanliness, become infected and give rise to sclerogenic inflam- 
matory edema. [An ulcerated infected lymphangioma of the vulva 
may produce a similar picture.] It has recently been pointed out 
that the clinical picture of esthiomene is perfectly reproduced in 
the ulcerative granuloma of the genital organs. 

Ordinary secondarily infected wounds or excoriations may finally 
suffice for the production of this pathological type, as a sequel of 
lymphangitis, sclerosis, or removal of the inguinal glands, etc. 
Esthiomene would in this way become entirely comparable to 
ulcer of the leg with elephantiasis nostras. 



312 ULCERATIONS AND ULCERATIVE DERMATOSES 

Treatment of Genital Ulcerations. — No matter what may be the 
cause and character of a balanoposthitis, phimosis or vulvitis, it 
is of great importance to keep the parts as clean as possible. If 
the glans cannot be uncovered for the irrigations, on account of the 
existing pain and inflammation, injections must be introduced into 
the subpreputial sack by means of a flexible rubber nozzle, begin- 
ning with lukewarm cleansing injections with large amounts of 
water, followed by astringent injections with a 1 : 100 silver nitrate 
solution, for example, or dilute peroxide water. 

Exposed erosions or ulcerations are treated by touching them with 
silver nitrate, tincture of iodine, etc., with bland non-fermentable 
mineral or medicated powders or finally with salves or creams. 

Keeping in mind, however, that cauterizations and numerous 
topical agents produce an induration which may become misleading, 
these should not be employed unless the diagnosis is already quite 
positive. 

In women, it is necessary to emphasize the manner in which the 
irrigations are to be used so as to be really efficient. It is often 
advantageous to prevent mutual contact between the parts, by 
inserting gauze or cotton tampons freely dusted with powders or 
covered with a layer of zinc ointment. 

In case of important or serious genital ulcerations, notably those 
of gangrenous appearance, the surfaces must be cleansed by local 
baths, moist dressings, washing with peroxide water or camphor- 
ated alcohol; next, iodoform powder may be applied, with a little 
salicylic acid or camphor, or according to the case, calcium chloride, 
balsam of Peru, etc. 

Needless to say, all necessary directions must be given for the 
avoidance of contagion. 

CUTANEOUS GANGRENE. 

Cutaneous gangrene means mortification or death of a portion of 
the integument and may be accompanied by the same changes in 
the underlying tissues. When it is abrupt and complete from the 
onset, it is named necrosis; when it results from a progressive loss 
of tissue vitality, it is called necrobiosis; this distinction is of small 
importance, the two processes being frequently combined. The 
"dead" portion is known as a slough or .sphacelus. It is distin- 
guished as dry gangrene and moist gangrene, according to its being 
dry and mummified, or on the contrary, moist, putrefying and fetid. 

Gangrene manifests itself as a change in color of the skin, which 
at the same time becomes cold and anesthetic to touch, pricking, 
and temperature. In the case of dry gangrene, the skin is yellow 
or purple, then brownish, and promptly hardens through desicca- 



CUTANEOUS GANGRENE 313 

tion, becoming depressed below the normal level. Moist gan- 
grene often begins as a purulent bulla, or rather as a bulla with 
sanious or hemorrhagic contents, the floor of which becomes necrotic ; 
or a flabby, mottled, grayish surface may on the next day become 
covered with sanious blebs. 

While sometimes unnoticed by the patient, the process in other 
cases is preceded or accompanied by stiffness, tingling, heat and 
intolerable laminating or tearing pains. 

After a few days, unless the necrosis proceeds very rapidly, the 
slough becomes surrounded by a congestive halo, sometimes bul- 
lous at its periphery; on the line of demarcation between the dead 
and the living tissue, a deep groove is formed which suppurates more 
or less freely. Having become dark brown or black, the sphacelus 
retracts and is finally cast off, exposing an ulceration covered with 
detritus, or sometimes pink and proliferating. 

The pathogenic mechanisms to which the various forms of cutane- 
ous gangrene are due, are multiple. In each particular case, there 
is reason to look for one or several of the following conditions, which, 
moreover, instead of excluding one another are very frequently 
associated : 

A. Direct local action of a mechanical, physical or chemical 
necrotizing agent. 

B. Suppression of the blood supply (through embolism, arteritis, 
etc.). 

C. Serious alteration of the blood itself. 

D. Necrotizing infection. 

E. Serious change of the trophic nerve supply. 

The last-named factor, often emphasized in the past (Zambaeo, 
1859), is at present considered as altogether accessory. Neuro- 
trophism may sometimes perhaps act as a favoring factor, but the 
existence of trophic gangrene or necrosis of trophic origin cannot 
be admitted. So-called hysterical gangrene is always artificially 
induced. 

The pathogenic mechanism from which certain secondary gan- 
grenes are derived, for example those which sometimes complicate 
erysipelas, anthrax, soft chancre, etc., or which originate in malig- 
nant tumors, cancers, sarcomas, the tumors of mycosis fungoides, etc., 
is probably complex and cannot always be definitely established. 

A. Direct Local Gangrene. — This results from an injury directly 
affecting the mortified point. Traumatic gangrene, as a sequel of 
crushing, severe contusions, war-wounds, belongs to the domain of 
surgery. Prolonged compression, for example by a very tight plaster 
apparatus, may produce a direct slough or ulceration. 

Decubitus may have the same effect on the compressed points, 
especially the sacral region and the trochanteric regions, much more 



314 ULCERATIONS AND ULCERATIVE DERMATOSES 

rarely the heels or the scapular regions, in patients whose nutrition 
is seriously impaired and whose vascular tension is lowered by a 
severe general disease or a disease of the nervous system (dementia, 
myelitis, hemiplegia, etc.). 

The sloughs of decubitus [bed-sores], which were formerly con- 
sidered as of trophic origin, are really due to the chronic irritation 
of the integument by contact with the urine, fecal matter, and cuta- 
neous secretions, in very weakened or hypersensitive individuals, 
with secondary infection of the macerated and excoriated skin. 
They can generally he avoided by extreme cleanliness, aseptic 
powders, and the employment of air-cushions. 

Physical causes, such as burns, frost-bite, contact with continuous 
current electrodes, high frequency -park-, ar-rays in excessive doses, 
will produce gangrenous patches at the damaged point-. 




Fig. 106. — Carbolic gangrene of the thumb, in a child aged five years, who had worn 
a carbolic acid dressing during one night, for a scratch made by a cat. 

Numerous chemical agents, so-called "caustics," notably strong 
alkali- and acids, certain -alt-, corrosive sublimate, zinc chloride, 
etc., will do the same. Sometimes, iodine tincture and even mus- 
tard plasters may produce sloughs, especially in children. 

Carbolic gangrene \> entitled to special mention, on account of its 
relative frequency and its insidious behavior. It is noteworthy that 
the total loss of a finger ha- repeatedly followed upon a simple 
panaris or whitlow, dressed with a solution of carbolic acid, even in 
supposedly harmless dilutions (Fig. L06). The patient is not warned 
by any painful sensation of the impending gangrene. It is therefore 
advisable to discard carbolic acid dressings, especially for the 
extremities. 

In the direct gangrenes, the injurious factor usually acts at the 
same time on the tis>ue constituents themselves and by producing 



C U TA NEO US GA NO RENE 



315 



stasis or thrombosis in the capillary bloodvessels. Infection, when 
present, is superadded. 

B. Gangrene of Vascular Origin. — Any portion of the organism 
in which the circulation of the blood is completely and permanently 
arrested, inevitably undergoes necrobiosis or necrosis. The venous 
system, which is rich in anastomoses, is rarely affected; gangrenes 
in the course of phlebitis, or of phlegmasia alba dolens, being of 
exceptional occurrence. Almost invariably, the obliteration is 
arterial, affects the extremities, and the gangrene is of the dry type. 
Vascular rupture, sometimes ligature, compression, embolism, 
especially thrombosis through acute or chronic arteritis, produce 
different forms of progressive gangrene of the extremities. 




Fig. 107. — Dry symmetrical gangrene of the toes. 



These gangrenes are observed especially on the feet, beginning 
with one or several toes, attacking at once the skin and the deep 
tissues, including the bones; hence they do not belong to the domain 
of dermatology. Only the principal types are here mentioned: 
Senile gangrene; gangrene due to obliterative endarteritis of 
Friedlander (Fig. 107) ; gangrene due to syphilitic arteritis [to endo- 
phlebitis migrans, Buerger]; gangrene in typhoid fever, etc. 

Gangrene of the extremities, as a rule, partial or limited to the 
fingers or toes, which occurs in the grave forms of Raynaud's dis- 
ease, is preceded by attacks of " local asphyxia" and " local syncope" ; 
it has been attributed to a vascular spasm, a mechanism which would 



316 ULCERATIONS AND ULCERATIVE DERMATOSES 

probably be incapable of producing this result. Its pathogenesis 
is not known. The rare cases of gangrene observed in progressive 
scleroderma may be compared with it. 

C. Gangrenes Through Changes of the Blood. —Under this head- 
ing I group the toxic gangrenes and those gangrenes which may be 
considered as autotoxic. 

Ergot of rye gave rise in the middle ages to epidemics in which 
the general phenomena of ergotism were associated with tingling 
sensations or severe pains and mutilating gangrenes of the extremi- 
ties. 

Carbon monoxide poisoning is capable of producing gangrene in 
large patches, or involving an entire extremity. Chloral, when 
administered for a long time and in large doses, has been accused of 
the same effects. The question of gangrenes in the course of Bright's 
disease, which are rather exceptional, is not well understood. 

Diabetic gangrene, on the contrary, is not uncommon. It is 
observed in individuals who are by no means cachectic, even in the 
enjoyment of excellent health and without large amounts of sugar in 
the urine. Assuredly neither hyperglycemia nor neuritis nor even 
arteritis can be held responsible, except perhaps in the massive 
forms. A slight traumatism or an accidental cutaneous affection 
often serves as determining cause. The principal part is probably 
referable to a local infection, streptococcic or other, or to septic 
embolisms. 

Massive diabetic gangrene may abruptly attack an extremity, 
an entire limb, the genital organs, etc. In other cases, gangrenous 
patches are scattered over the feet, the lower limbs, or elsewhere, in 
the form of grayish or brown sloughs, preceded by a blister and pro- 
gressively extensive. In this form — named bullo-serpiginous, by 
Kaposi — the center may heal while a bullous elevation at the periph- 
ery marks the zone of invasion. The course is rapid or on the 
contrary very sluggish. The prognosis in a general way is not very 
unfavorable. 

When gangrene in diabetics is secondary to suppurative lesions, 
furuncles, carbuncles, abscess, etc., the symptoms of reaction may 
be mild, although the situation is really threatening. 

D. Gangrenous Infections. — Infection through bacteria of various 
kinds, ordinary or special, aerobes or perhaps especially anaerobes, 
plays a considerable part in the origin and in the course of cutaneous 
gangrenes. 

It seems logical, a priori, to group under two separate headings: 
(1) Secondary infected gangrenes, in which a lesion or affection of 
the skin, of definite character (wounds, ecthyma, furuncle, erysipelas, 
pemphigus, varicella, zona, syphilide, soft chancre, etc.), becomes 
gangrenous through the effect of an excessive virulence of its causa- 



CUTANEOUS GANGRENE 317 

tive agent, a diminished resistance of the organism, or the introduc- 
tion of necrotizing germs from the outside; (2) primary infectious 
gangrenes, resulting from microbic embolism in the skin by the 
hematogenous route. Sometimes, the direct examination of the 
patient or the history will show at first sight that the case belongs 
to one or the other of these groups; in other instances, there remains 
a doubt. 

There is little advantage in dwelling upon the secondary or acci- 
dental infectious gangrenes. I shall therefore discuss only those 
which are primary and essential; leaving aside, of course, the gan- 
grenes of the classified general diseases, such as anthrax, bubonic 
plague, etc., and discussing instead the clinical forms of dermato- 
logical character. 

Multiple Gangrene of Children. — This is a somewhat unusual 
clinical type, comprising positively dissimilar forms, such as those 
cases which have been described under the names of multiple 
cachectic gangrene of the skin (O. Simon and Eichhof), gangrenous 
dermatitis of children, gangrenous varicella, gangrenous ecthyma, 
gangrenous urticaria, purpura fulminans, etc. 

Instances have been observed in very young children, especially 
girls, and in weakened individuals. Sometimes, the impression of 
a special disease is conveyed; in other cases, one is apparently con- 
fronted with an extraordinarily malignant form of an exanthem 
(varicella, vaccinia, measles) or of a pseudo-exanthema (purpura, 
polymorphous erythema) . 

In a few days, a more or less abundant eruption of erythematous, 
urticarial or purpuric spots makes its appearance, or there may be 
bullae containing a reddish serous fluid, or pustules, which enlarge 
and multiply. Their center very promptly turns black; the slough, 
concealed or not by a crust, spreads more or less, then becomes 
surrounded by a suppurative groove and loosens, leaving a per- 
pendicular or dome-shaped ulceration with a sanious floor. The 
coalescence of several lesions gives rise to festooned patches. The 
sloughing may destroy a portion of the nose, of the lips, of the lobe 
of the ear, of the external genitals, or of the fingers and toes. Nodosi- 
ties, edemas and abscesses may also be met with. 

The eruption is situated especially on the lower portion of the 
trunk and on the thighs; it has another site of election on the neck, 
on the scalp, and on the face; but it may be widely disseminated. 

The general symptoms are of very variable severity, sometimes 
only slightly marked; but often the condition is associated with a 
high fever, digestive disturbances, prostration, convulsions, as well 
as visceral complications leading to death; the mortality is about 
50 per cent. In favorable cases, recovery is rapid. 

Numerous pyococci and bacilli have been held responsible. In 



318 



ULCERATIONS AND ULCERATIVE DERMATOSES 



the carefully studied case of Veillon and J. Halle, the pathogenic 
agent was the bacillus ramosus; it is probable that other anaerobic 
microbes may produce analogous phenomena. Recently a few eases 
could be referred to the meningococcus. 

Multiple Gangrene of Adults. No discussion is here called for of 
the gangrenes with multiple foci, accompanied by abscesses and 
gangrenous phlegmons, which occur in rare instances in the course 
of pestilential diseases, very advanced cachexias and severe diseases 
of the nervous system. These arc cases of septic embolisms with 
anaerobic microbes, of genuine metastases, derived from a bed-sore 
or a gangrenous focus of any kind, especially a pulmonary gangrene. 




Fig. ids 



Multiple gangrene of adults; of filteen days' standing, in a man aged 
seventy-one years in good health. 



However, gangrenous eruptions entirely analogous to those of 
children, are also encountered in youthful individuals, in good 
health or slightly weakened and even in adults of middle age. They 
have the same onset, the same local symptomatology, the same 
genera] symptoms ami develop in successive attacks. Examples 
have been quoted by Doutrelepont, Hallopeau, Carle, Brocq. 1 
have personally observed several rather dissimilar cases, some with 
multiple patches limited to a single region (Fig. ION), others with 
very numerous lesions scattered over the entire integument. The 
prognosis is grave, although not necessarily fatal. Mention has been 
made of possible contagiousness 1 1 >emme). 



CUTANEOUS GANGRENE 319 

Fulminating Gangrene of the Genital Organs. — A. Fournier has 
pointed out a rare type of gangrene, observed especially in young 
adults, leading to grave mutilations, sometimes to death. 

Usually as the result of a slight excoriation, there suddenly 
develops, without paraphimosis, an enormous rose-colored edema 
of the penis and scrotum, with chills, high fever, etc. At the end 
of twenty-four to thirty-six hours, the penis after having assumed 
the appearance of a large "clapper," presents purplish, black or 
white gangrenous patches, which may destroy the entire sheathes, 
often the scrotum and rarely the corpora cavernosa; the swelling- 
subsides at the end of about a week. 

A very virulent streptococcus has been found in the serous dis- 
charge. These are probably cases of gangrenous erysipelas. 

Treatment. — All cutaneous gangrenes are difficult to treat. 
Hygiene and general medications must not be too much relied on; 
even in the cases of diabetic gangrene, where a strict diet is impera- 
tive, this cannot prove sufficient by itself alone. 

Locally, it is essential to supervise scrupulous cleanliness and well- 
applied protective dressings. In some cases, moist aseptic dressings 
are useful, or the application of dilute peroxide water, or even pro- 
longed local baths; but as a rule, dry or oily dressings are preferable. 
Dressings with strong antiseptics are frequently injurious. 

The parts may be swabbed with camphorated alcohol, or with a 
weak solution of potassium permanganate, followed by wrapping 
in dry sterilized cotton; or large quantities of aseptic or weakly 
antiseptic powders may be used (quinine, iron subcarbonate, der- 
matol, iodoform). Oily dressings, with carron-oil, guaiacolized oil, 
etc., are often better liked and seem to act more favorably. 

When the gangrene is progressive it may be of vital importance to 
destroy the focus of putrefaction and the neighboring zone of inva- 
sion. This is accomplished by applications of superheated air in 
jets under pressure; this requires special apparatus, experience and 
skill, but actually constitutes the best treatment against extensive 
gangrenes, diabetic as well as others. The hot-air method is prefer- 
able to surgical removal, which will only be called for after the proc- 
ess has been checked, for the resection of sequestra or the trimming 
of stumps. 



CHAPTER XVI. 
DYSCHROMIAS. 

Cutaneous Pigments. — The human skin is normally pigmented 
throughout; in this respect, there are merely differences in degree 
between the white race and the colored races, between the different 
regions of the body and between individuals of the same race. 

The physiological cutaneous pigment consists of extremely small 
brown or black grannies of an organic substance named melanin, 
which contains no iron, but sulphur in variable proportion. The 
melanin granules are situated in the basal layer of the epidermis 
and, furthermore, when the pigmentation is very marked, in certain 
cells of the papillary body; the color of the hairs and of the choroid 
is likewise due to melanin. 

Under pathological conditions, two other pigments may be met 
with, hemosiderin, an ochre pigment which gives the reactions for 
iron and is formed in bloody extravasates, becoming deposited 
exclusively in the cutis; and the paludean pigment which is charac- 
teristic of malarial melanodermia. 

Except in cases which will receive special consideration, the dys- 
chromias are due to variations in the amount of melanin. 

Dyschromias. — The name "dyschromia" is applied to pathological 
changes in the color of the skin, resulting either from an excess or a 
deficiency of pigment. They do not disappear on pressure with the 
finger, resist all washing, etc., and ordinarily persist a long time, 
sometimes throughout life. 

As a rule, there is an excess of pigmentation. These hyper- 
chromias may be circumscribed, representing pigmentary spots; or 
diffuse, representing melanodermas. 

Hypochromic, and achromia are more uncommon. 

When the latter is congenital, it is known as albinism; it may be 
generalized or localized. Complete albinism, in which there is a more 
or less total absence of pigment in the skin and its appendages, is a 
grave degeneration, very rare in the human race. Albinos have a 
waxy skin, white or very light colored hair on the seal]) and body 
and ;i red or bluish iris. 

Partial congenital achromia is the exact oppositeof a pigmentary 
nevus; it is often familial, circumscribed in a nerve territory of only 
one side of the body, or it may consist of a few white spots, known 
as achromic nevi. 



ARTIFICIAL AND SECONDARY DYSCHROMIAS 321 

Acquired hyperchromia is known as leukoderma and is usually 
secondary to a local process. It is frequently associated with 
hyperchromia at neighboring points, constituting the leukomelano- 
dermas of vitiligo and some other analogous affections. 

The causes of the dyschromias are extremely variable, and this 
pathogenic mechanism is far from being entirely understood. 
Among these causes, some act locally, while others are of a general 
kind, such as intoxications, infections, changes of the blood, nervous 
disturbances. 

In both these cases, the pigmentation may assume the form of 
more or less circumscribed spots or it may become diffused over 
surfaces. The generalized melanodermas are always referable to a 
general cause. In the leukomelanodermas, the intervention of a 
nervous disturbance is usually admitted as essential. 

For the diagnosis of a dyschromia it is first of all necessary to 
ascertain : if it is secondary to another process (macules) or primary 
or essential; if it is simple, without other changes of the integument, 
or associated with a dermatosis of different character; if it is circum- 
scribed (pigmentary spots) or diffuse (melanoderma), generalized or 
regional. 

The dyschromic syndromes to be discussed in the following have 
been arranged according to this plan; a paragraph has been added 
on the subject of vitiligo and other leukomelanodermas. 

Finally, although these conditions are not due to pigmentary 
disturbances but to foreign bodies, a few lines are devoted to 
tattoo-marks and argyria. 



ARTIFICIAL AND SECONDARY DYSCHROMIAS. 

Artificial Pigmentations. — Any cutaneous irritation, especially 
when fairly strong and prolonged, may become the origin of an arti- 
ficial local pigmentation. Certain individuals are evidently predis- 
posed to it and its production is favored by stasis of the blood, as 
for example in varicose legs. 

In some cases, the pigmentation is the direct and exclusive result 
of the irritation; in others it follows upon a hyperemia or even a 
bullous or eczematous process, etc., belonging in the last-named 
case to what I describe as macules. 

Mechanical factors, friction by the clothing, corsets, shoes, 
bandages, repeated scratching in pruritus, give rise to hyperchromias 
of an often characteristic seat and configuration. 

Among pigmentations due to physical factors, it suffices to call 
attention to the following: the tanned complexion produced by 
sunlight, the open air, electric light, the a'-rays; the caloric pigmen- 
21 



322 DYSCHROMIAS 

tatioD of the face, forearms and trunk in blacksmiths, glass-blowers, 
bakers, etc.; of the thighs, in out-of-doors hucksters who have the 
habit of sitting on their foot-warmers and of any region of the body 
in persons who have abused hot compresses <>r very hot lotions for 
the nlicf of pain, pruritus, etc.; this is often arranged after the 
fashion of a wide-meshed network. [The dermatitis calorica of 
furnace men and others exposed to great heat is commonly followed 
by this reticular pigmentation.] Many chemical agents may cause 
very persistent pigmentations, even without a caustic action; and 
it is well for the physician to he forewarned, so as to avoid reproach 
under some condition-. This remark applies to nearly all rube- 
facients and counter-irritants, notably mustard plasters, methyl 
chloride, chloroform, tincture of iodin, etc. Applications of chrysa- 
robiii usually give rise to a bronzed erythema, followed by an 
extensive but temporary brownish pigmentation from which the 
healed patches of psoriasis stand out in white. 

The treatment of the artificial pigmentations consists in the 
removal of the cause of the hyperchromia and in the employ- 
ment of topical agents which will be discussed in connection with 
chloasma. 

Macules.- I June for a long time been accustomed to reserve 
1 1 1 i s name, which is popularly used interchangeably with the word 
spots, for the dyschromic but not cicatricial residues of a large 
number of cutaneous affections. 

They follow upon excoriations, upon erythematous, vesicular, 
eczematous, bullous eruptions, such as burns, blisters from vesicants; 
purulent bulhe of impetigo; superficial folliculitides; the multiple 
lesions of scabies; papules of all kinds, etc. 

They consist of a local, often distinctly circumscribed, pigmenta- 
tion or sometimes of a central hypochromia surrounded by a pig- 
mentary halo. They are often scaly at the onset and then of a 
perfectly normal surface. 

In the absence of sufficient observation or information, maculae 
may lead to numerous errors of diagnosis. It is necessary to guard 
against the confusion of macula?, whose epidermis has its normal 
structure and which are always temporary, with deaf rices- which 
are always permanent. 

The seat, extent and configuration of the macules often possess 
important indicative value in regard to the causative dermatosis. 
The hyperchromic tendency of syphilitic papules of all kinds, in 
certain individuals, has long been emphasized. These syphilides 
nigricantes, to use A. Founder's term, are sometimes a source of 
great distress for the patient. 

A special group of pigmentary macules of hemorrhagic origin, in 
which the pigment is hemosiderin, is represented by the brown 



PIGMENTARY SPOTS 323 

spots following on traumatic or purpuric ecchymoses, hemorrhagic 
urticaria, varicose eczema, etc. 

Under the name of pigmentary dermatosis of the legs (or dermite 
jawne d'ocre) have been separately described large more or less 
distinctly outlined spots of a uniform brown or mottled color, which 
are frequently observed on the legs of arteriosclerotic, varicose or 
diabetic individuals, or in Bright's disease, etc., and which persist 
indefinitely. They result from minute interstitial frequently repeated 
hemorrhages. 

ASSOCIATED DYSCHROMIAS OR DYSCHROMIC DERMATOSES. 

Several dermatoses give rise to a black or dark coloration of the 
integument which is not dyschromic, in so far as it results exclusively 
from an abnormal hue of the horny layer. In such cases, the colored 
layer can be finally detached by energetic scratching. This occurs 
in many hyperkeratoses and keratodermas, in ichthyosis niger, in 
psorospermosis follicularis, in certain seborrheas nigricantes, in 
pityriasis versicolor, in the carates [pinta], etc., and to a less degree, 
in kerosis. 

Some dermatoses are actually pigmentary anomalies or may 
lead to such. Spots from antipyrin and from leprosy are, as a rule, 
ery themato-pigmented . 

Various eruptions will be mentioned further on, which may be 
accompanied by a sort of pigmentary ataxia, such as lichen planus, 
various prurigos, etc. 

Pigmentations also form an essential part of the pathological 
disturbances of acanthosis nigricans, xeroderma pigmentosum and 
several analogous cutaneous dystrophies; of v. Recklinghausen's 
disease and urticaria pigmentosa. 

The reader is finally reminded of the pigmentary tumors, malig- 
nant, such as the nevo-carcinomata or pigmented sarcomas; or 
benign, such as pigmented nevi. 

In this entire group of associated dyschromias, it is the underlying 
dermatosis, characterized by its peculiar lesions which establishes 
the diagnosis, governs the prognosis, determines the treatment and 
explains the pigmentation. 

PIGMENTARY SPOTS. 

Ephelides. — Ephelides, or freckles, confused by some derma- 
tologists with lentigo, are small lenticular, rounded or oval, more 
rarely irregular spots, of a light yellow, cafe-au-lait or brownish 
color, perfectly flat, smooth and not scaly, generally isolated and 
numerous, or very profuse and agminated if not confluent, sym- 
metrically arranged, having their seat of predilection on the face, 



324 DYSCHROMIAS 

the nose, the prominences of the cheek bones, the forehead, the 
hands and forearms. More rarely, they are scattered over the 
shoulders, the arms, the legs, the buttocks and the genitals. 

Ephelides are not congenital, but appear during childhood and 
youth, especially in blond or red-haired, anemic or lymphatic indi- 
viduals and in persons enjoying excellent health. 

Sunlight undoubtedly plays a considerable part in the mechanism 
of their onset, as suggested by their name; also, they are much more 
apparent during the spring and summer than in winter. But on 
the other hand, they are plainly hereditary or atavistic in certain 
families; they develop also in covered regions of the body and are 
in every way comparable to nevi. 

The histology of ephelides shows merely an abnormal quantity of 
pigment in the basal epidermic cells, with presence of pigmentary 
cells in the papillary body. 

Chloasma. — Chloasma uterinum consists of spreading spots, 
irregular in shape and outline, sometimes confluent in patches, of a 
yellow, brownish, or still darker color, situated almost invariably 
symmetrically on the forehead, the temples, the lateral portions of 
the cheeks and more rarely on the eyelids, the chin, or at other 
points of the body. The well-marked outline of chloasma dis- 
tinguishes it from the caloric and solar pigmentations. 

Chloasma ordinarily develops in pregnant women and persists 
until the reestablishment of menstruation and often throughout 
life. At the same time, or even in its absence, there appears a pig- 
mentation of the linea alba, the areola of the nipples and the vulva, 
especially in brunettes. Various pathological conditions, metritis, 
salpingitis, dysmenorrhea, etc., may produce identical pigmenta- 
tions. Cases of chloasma without a demonstrable cause are also 
met with. 

It seems probable to me that an irritation of the abdominal 
sympathetic nervous apparatus enters into its pathogenesis, as in 
the case of Addison's disease [and probably in acanthosis nigricans.] 

The treatment of chloasma, like that of the ephelides and arti- 
ficial pigmentations, yields no satisfactory results. Prophylactic 
measures would be the most advisable, with avoidance in predis- 
posed persons, of cutaneous irritation or exposure to light; suitable 
treatment of uterine and abdominal affections or anemia and the 
lymphatic constitution when present. The administration of 
arsenic, which produces hyperchromia, is contra-indicated. 

Locally, so-called decolorizing washes may be prescribed, appli- 
cations of mercurial plasters during the night, or salicylated calomel 
partes, or some peroxide cream. Exfoliation by means of exfoliating 
pastes is often successful in decolorizing the hyperchromic surfaces, 
but the cure is as a rule merely temporary. 



DIFFUSE DYSCHROMIAS AND MELANODERMAS 325 

Disseminated Pigmentary Spots. — As has just been shown, the 
ephelides and chloasma are regional affections. In the presence of 
disseminated yellow or brownish pigmentary spots, or a single spot, 
it is necessary to think in the first place of the artificial, macular 
and secondary pigmentations which have been discussed in the 
preceding paragraphs; next, of the pigmentary nevi and of v. Reck- 
linghausen's disease, which includes some abortive forms, exclu- 
sively pigmentary; finally, one must keep in mind the possibility 
of circumscribed pigmentations in several melanodermas due to 
general causes. 

The blue or shaded spots produced by the bite of phthirius 
inguinalis or the crab-louse, are characterized by their peculiar 
slate-blue coloring. They are of irregular form, of lenticular or 
nummular dimensions; the epidermis is in no way changed; they 
cause no itching and are of ephemeral duration [up to a week or 
more]. They are situated in variable numbers on the abdomen, 
the thighs, the back, and sometimes on the chest. The experiments 
of Duguet have shown them to be due to the local action of the 
venom of the parasite. 

DIFFUSE DYCHROMIAS AND MELANODERMAS. 

Diffuse pigmentations, whether generalized or, what is more 
common, regional or with regional predominance, are referable to : 
chronic infections, such as tuberculosis, syphilis, leprosy and pellagra ; 
or to intoxications, such as arsenicism and phthiriasis; or to a variety 
of blood diseases; or to diseases of the nervous system. Occasionally, 
leukoderma is intermingled with hyperchromia. 

Addisonian and Tuberculous Melanodermas. — In Addison's dis- 
ease, the bronzed coloration of the integument is often delayed; 
but. it may also precede by several years the other symptoms, such 
as asthenia, digestive disturbances and lumbar pains. The pig- 
mentation, which is diffuse, of a red-brown or gray-brown color, 
first involves and stains the genital organs, the areolae of the 
breasts, the articular folds and the uncovered portions, face and 
hands, and long-standing or recent scars. Jacquet has shown that a 
local irritation may "externalize" a latent tendency to pigmenta- 
tion. On the hyperchromic surfaces, normal areas simulating 
leukodermic spots are sometimes seen. 

Very commonly the pigmentation involves also the buccal mucosa, 
where tan or brownish spots, distinctly outlined or with diffuse 
margins, are noted on the cheeks, the lips, the tongue, the gums 
and the palate. [Pigmentation of the mucosa sometimes precedes 
that of the cutaneous surface.] The cutaneous and mucous lesions 
consist of an excess of melanin in the epidermis and cutis. 



326 DYSCHROMIAS 

The melanoderma of Addison's disease is now known to be 
referable, not so inneh to a change of the suprarenal bodies them- 
selves as to a lesion or irritation of the pericapsular sympathetic 
nerve apparatus which apparently presides over the regulation of 
the pigment. It has occurred to me that the pigmentations of 
acanthosis nigricans, of chloasma and perhaps that of pigmentary 
syphilides, may have an analogous pathogenesis. 

The melanoderma of tuberculous patients has long been known, 
especially in cases of tuberculous peritonitis or enteritis. It con- 
sists of a dusky or brownish coloring of the genitals, the abdomen 
and sometimes the neck. It evidently results from the same condi- 
tions as genuine Addison's disease, from which it differs as a rule 
only by its more limited diffusion especially on uncovered parts. 

Pigmentary Syphilides. — Aside from the posteruptive pigmentary 
macules referred to before and the tertiary leukomelanodermas to 
be discussed further on, syphilis very frequently produces a truly 
specific areolar pigmentation of the neck, which ranks among its 
most significant symptoms. 

This areolar pigmentary syphilide is more common in women 
than in men. It appears as early as the second or third month, or 
in the course of the first year, rarely after two years and has a very 
indefinite duration which it is very difficult to determine [five to 
fourteen months, according to Jadassohn]. It consists of a grayish 
or brownish more or less dark hyperchromia, with diffuse borders, 
interspersed with islands of distinctly outlined white spots varying 
in size from a lentil to a franc, so that the whole forms a network 
with large strands, usually better marked on the lateral portions 
of the neck (Fig. 109). This "necklace of Venus" may send radiat- 
ing processes on the chest, often in front of the axilla 1 , on the flanks, 
or still farther. In some cases, pigmentary macules are found in the 
center of a few of the white areola 3 . 

The pathogenesis of areolar syphilide is still a matter of contro- 
versy. By some, the pigmentation is interpreted as the primary 
and exclusive feature, the apparent decoloration of the meshes being 
referable to a contrast-effect; others assume true leukodermic patches, 
following upon a sometimes not very evident eruption, which become 
secondarily surrounded by hyperpigmented areas. 

It is more than probable that both these interpretations are 
correct in different cases and that there are really two modes of 
formation of the pigmented network. 

This dyschromia is almost pathognomonic. However, a few old 
observations are on record of areolar pigmentations of the same type 
referable to tuberculosis and chlorosis; these date back, it must be 
noted, to a period prior to the discovery of the serodiagnosis of 
syphilis. 



DIFFUSE DYSCHROMIAS AND MELANODERMAS 327 

Inversely, pigmentations of another type, analogous to chloasma, 
for example, have been noted in secondary syphilis. 

The syphilitic hyperchromias are practically not amenable to 
specific treatment. 




Fig. II 



-Areolar pigmentary syphilide of the neck. (After a east in the Museum 
of the St. Louis Hospital.) 



Dyschromias of Leprosy. — The initial erythemato-pigmented 
spots, leprous pemphigus, tubercles, infiltrations and ulcers often 
leave behind them hyperchromic or plainly achromic spots, or 
leukomelanodermas resulting from a combination of these two 
opposite disturbances. 

For instance, white spots with a pigmented border may be 
observed — annular, band-like, or diffuse, or dark surfaces dotted 
with colorless spots, etc. 

All these various manifestations, which were formerly designated 
under the names of melas, leuke, morphea alba et nigra, vitiligo 
gravior, are usually characterized by anesthesia. 

The distribution of the pigment is variable. Hansen's bacilli are 
almost regularly demonstrable in sections of the skin, although in 
very small number. 

Dyschromias of Nervous Diseases. — In the organic diseases of 
the nervous system, the disturbances of pigmentation are usually 
not pronounced. 

In hemiplegia, cerebral tumors, infantile paralysis, progressive 
muscular atrophy, syringomyelia, tabes, the traumatic or toxic 
neuritides, etc., slight modifications in the coloring of the skin have 
been reported, associated with other trophic disturbances, hyper- 
trichosis or alopecia, hyperidrosis, etc. The same observations have 
been made in mental diseases of the depressive or melancholic type. 



328 DYSCHROMIAS 

On the contrary, the dyschromias are abundantly represented on 
the borderland of nervous pathology, in diseases placed here by 
their symptoms. In Raynaud's disease, in myxedema, in exoph- 
thalmic goitre, they are of frequent occurrence; vitiligo is rather 
common in Graves' disease. 

In scleroderma under its different aspects, which can hardly be 
considered simply a nervous disease and in facial hemiatrophy, 
which is related to it in some respects, hyperchromia is a nearly 
constant symptom. A more or less deep, diffuse, areolar or spotted, 
primary or delayed pigmentation is noted, occupying the sclerotic 
areas, or the neighboring regions, or sometimes a large extent of 
the integument. Depigmentation of the sclerotic patches or regions 
i- also not uncommon. 

Dyschromias in Diseases of the Blood and in Cachexias. — It is 
enough to mention the hypochromia which may be seen in chlorosis, 
the chloro-anemias, pernicious anemia, the leukemias and in cancer- 
ous cachexia. 

Inversely, it is not exceptional to observe various diffuse or 
regional melanodermas in these diseases more particularly in Banti's 
disease and in the psendo-leukemias. 

The melanoderma of bronzed diabetes, with or without pigment- 
ary hypertrophic cirrhosis, is generalized, almost invariably spares 
the mucous membranes and consists of an infiltration into the cutis 
as well as other tissues, of an ochre-colored pigment known as rubigin. 

In malarial cachexia, the coloration is ashy, a dirty gray, or yellow 
gray, diffusely and uniformly distributed. The malarial pigment, 
which is specific, is derived from the malaria-parasites, is carried to 
the skin by the blood (melanemia), and is here deposited, associated 
with an ochre pigment of hemic origin [hemosiderin]. 

Arsenical Dyschromias. — Arsenical melanoderma may develop 
independently of the age and sex of the patient or the nature of the 
arsenical remedy and its mode of introduction. Very minute doses 
are sometimes sufficient for its production, although as a rule, a 
prolonged absorption, medicinal, occupational, or accidental, is 
responsible. 

The pigmentation may assume two forms which are sometimes 
combined; that of diffuse hyperchromia predominating in normally 
colored areas, cicatrices, or cutaneous regions which are subject 
to pressure, or that of pigmentary spots, which enlarge and become 
confluent. In patients who have been improperly treated with 
arsenic for psoriasis or lichen, a very deep generalized melanoderma 
is sometimes observed. 

The coloration is iron-gray, bronzed, or even black. The 
uncovered regions remain relatively free, as well as the mucous 
membranes, with very rare exceptions. 



VITILIGO 329 

Pediculous or Phthiriasic Melanoderma. — In paupers, tramps, 
scavengers and rag-pickers living in filth and misery, exposed to all 
sorts of vermin and whose clothing sometimes harbors incredible 
numbers of pediculi corporis, this condition is known to occur, 
so that the name of Vagabond's disease is usually entirely justified. 

The pigmentation, of a dirty brown mottled with excoriations, 
crusts and cicatrices, predominates on the back, the nape of the neck, 
the shoulders, the waistline, and the thighs; but it may spread all 
over the integument, including the face and the extremities. 

Thibierge has shown, and I was repeatedly enabled to verify the 
fact, that the pigmentation is observed even on the buccal mucosa, 
in the form of spots resembling those of Addison's disease. 

The hyperchromia has been attributed to scratching, to bloody 
extravasations and to the local action of the venom of the lice. 
Its generalization and its possible localization in the mouth, show 
that this poison has a systemic action. The asthenia, the often very 
cachectic appearance of the patients, and the digestive disturbances 
from which they suffer, are additional proofs of this contention and 
help to render the differential diagnosis from Addison's disease very 
difficult in some cases. 

VITILIGO. 

Vitiligo is a non-congenital dyschromia characterized by the 
appearance of achromic or strongly hypochromic white spots, which 
are sharply limited and surrounded by a more or less extensive zone 
of hyperpigmentation. 

Aside from the change in color, the skin presents no alteration 
of its surface, consistence or function. 

The white spots of vitiligo have a milky or ivory hue, a dull 
sheen, a generally round, oval, or polylobular form, distinct faintly 
sinuous outlines. Sometimes they are in small numbers, but in 
other cases they may be so profuse and numerous as to cover a 
large portion or nearly the whole of the integument (Fig. 110). 

The hyperchromia of the intermediate regions, which have a 
brown or grayish hue, is often particularly marked at the very 
border of the white spots; this arrangement conveys the impression 
of the pigment having been pushed out from the achromic surfaces. 
At the periphery of the hyperpigmented zones, the transition into 
the normal color is gradual and imperceptible, rarely marked by a 
distinct boundary. 

The down and hairs of the white spots are either entirely colorless 
or of normal color. 

The dyschromia is associated with no sensory disturbance, neither 
pain, nor itching, nor noteworthy anesthesia being demonstrable. 

Jadassohn points out that the white spots are more susceptible 






DYSCHROMIAS 



to solar erythema, while they arc on the contrary more resistant 
to various cutaneous irritations and relatively immune to certain 
eruptions. 

The topography of vitiligo is extremely variable, not infrequently 
its distribution is more or less symmetrical. It may occupy any 
region, although it show- a certain predilection for the back of the 
hands, the wrists and the forearms, the face and neck and for the 
genital organs and the neighboring areas. The mucosas are always 
intact. 

The course of the affection i- governed by no rule; it may appear 
suddenly or more often insidiously; it- extension i- gradual and 
almost imperceptible or sometime- occurs in successive attacks. 



f « Ji 

Hi*- r 





110.— Vitiligo. 



The dyschromia may remain almost stationary, with seasonal 
variations of its shade-; more commonly, the white spot- spread 
and become confluent in patches; they may even become generalized; 
Inn at the same time the degree of the hyperchromia diminishes. 
A complete cure is very rare. 

The etiology of vitiligo is unknown. Adolescence, youth and the 
female sex seem to be relatively predisposing. It has been known 
to occur in persons who had been exposed to a nervous or emo- 
tional shock. Repeated traumatisms certainly play a part, for 
vitiligo is not rare at point- exposed to friction a-, for instance, 
from a hernial truss. 

Moreover, it becomes associated too frequently for a merely 



SECONDARY LEUKODERMAS AND LEUKOMELANODERMAS 331 

accidental combination, with alopecia, circumscribed prurigos, 
lichen planus, scleroderma and with a variety of nervous diseases, 
notably tabes dorsalis and exophthalmic goiter. 

Like several writers, I have been struck with the relative fre- 
quency of syphilis in patients with vitiligo; however, there is at 
present no reason for admitting the existence of a syphilitic vitiligo, 
nor especially that all vitiligo depend upon this infection. 

The pathological anatomy shows the almost complete disappear- 
ance of the pigment in the leukodermic spots and its abundance 
on the contrary in the epidermis and derma of the hyperchromic 
regions; but it affords no information as to the pathogenesis of 
these lesions. 

The diagnosis is very easy in the vast majority of the cases. An 
even cursory examination suffices to guard against confusion with 
pityriasis versicolor and with the various pigmentations, circum- 
scribed or diffuse, but without achromic spots, which have been 
mentioned in the course of this chapter. The light areolas of the 
pigmentary syphilide of the neck, which is moreover characterized 
by its seat, as well as those which may eventually be encountered 
in various melanodermas, are usually preserved normal skin areas 
and not leukodermas. 

The only real difficulties which may present themselves are the 
following: In the course of leprosy, pigmented surfaces and 
achromic spots have been demonstrated and as a whole have been 
designated as vitiligo gravior; very evident sensory disturbances are 
present in these cases. 

In certain families of temperate zones and more frequently in 
the colored races, congenital leukomelanodermas or cases of partial 
albinism have been noted ; the dyschromia in these cases is absolutely 
stationary and sometimes symmetrical. So-called piebald negroes 
are probably in part referable to this congenital anomaly and in 
part to vitiligo or to leprosy. 

The treatment of vitiligo usually is not very effective. In those 
cases where syphilis seems to be involved, or in the coexistence 
of tabes, mercurial treatment should be administered and I have 
obtained a remarkable success in one instance. It is to be 
feared that arsenic may aggravate the hyperchromia. As a rule, 
nothing can be done but to regulate the patient's general hygiene, 
to prescribe sedative or tonic hydrotherapy and electric treatments. 
Various opotherapies might be indicated in this affection. The 
overpigmented zones may be treated with the customary decolorizing 
agents. 

Secondary Leukodermas and Leukomelanodermas. — These are 
distinguished from vitiligo by this essential characteristic that the 
dyschromia here is not simple, but accompanies an eruptive mani- 



332 DYSCHROMIAS 

festation, or a change in the thickness, consistence and structure 
of the skin. 

There is a coexisting eruption, with disturbances in pigmentation, 
in lichen planus, lichen hypertrophicus, circumscribed prurigo, etc. 

There is sclerosis or atrophy of the skin in the following cases: 
the leukodermic spots of circumscribed scleroderma, also known as 
morphcea nostras, which are bordered by a lilac ring; the morphcea of 
lepras)/ which is anesthetic and contains Hansen's bacillus; the 
cutaneous atrophies in patches, often preceded by an erythematous 
stage; lichen planus- atrophicus which has been papular; sclerotic 
radiodermatitis, which is interspersed with telangiectases. 

Cicatrices, no matter of what origin, as well as linear atrophies 
are sometimes pigmented or leukodermic and in the latter case 
often surrounded by a zone of hyperchromia. This is of especially 
common occurrence in the cicatrices of tertiary syphilis. Under 
the name of syphilitic leukomelanodermas, extreme cases have been 
described, by A. Fournier, Gemy, etc., in which the skin finally 
becomes mottled with black spots, or sometimes with rounded or 
polycyclic white spots in the midst of pigmented surfaces, so as to 
simulate vitiligo from a distance. 



TATTOO MARKS AND ARGYRIA. 

Tattoo marks are spots on designs produced by the deliberate 
introduction of colored and insoluble particles into the cutis where 
they persist indefinitely. 

These more or less artistic tattoo marks and inscriptions are 
usually made with lamp black or India ink when they are blue, or 
with vermilion when they are red; the colored powder is made to 
penetrate by means of closely bunched very fine needles. Tattoo 
marks are commonly seen in sailors, colonial soldiers, prostitutes 
and their cadets; but also occasionally in the educated classes, as 
the effect of a peculiar aberration. 

Powder spots, resulting from a gunshot fired at close range and 
from the penetration of bits of charcoal, have a characteristic 
arrangement. 

In certain occupations, among grinders, filers, stone-breakers, 
miners, etc., particles of steel, Mint, or coal, may penetrate into the 
cutis and cause a sort of occupational tattooing. 

Electrolysis, or hypodermic injections applied with steel needles, 
may likewise leave prints of siderosis. 

Argyria is a slaty coloration, with bluish reflexes, which develops 
in persons exposed to the prolonged absorption of silver nitrate 
pills or other silver salts. It is generalized, but much more pro- 



TATTOO MARKS AND ARGYRIA 333 

nounced on the face, the hands and the articular folds and may also 
affect the mucous membranes. 

The silver granules, conveyed by the bloodstream, impregnate 
especially the elastic fiber and the capillaries, sparing the cellular 
elements. 

Spots of local argyria may be encountered on the buccal, con- 
junctival and vulvar mucosa?, following upon energetic cauteriza- 
tions with lunar caustic. [Very distressing cases of local and even 
quite extensive argyria have followed the use of the organic silver 
compounds in the treatment of dachryocystitis.] 

Treatment. — In order to remove tattoo-marks, which is difficult, 
various caustic agents may be used. Variot recommends retattooing 
with a concentrated solution of tannin and then passing a silver 
nitrate pencil over the surface. A dry slough is formed, which 
brings the tattoo mark away with it, provided the slough is deep 
enough. I have advantageously employed crossed linear scarifica- 
tion followed by cauterization with pure carbolic acid. Applica- 
tions of carbonic acid snow have also been recommended. 



CHAPTER XVII. 

CUTANEOUS ATROPHIES, SCLEROSES AND 
DYSTROPHIES. 

Cutaneous atrophy is a nutritional disturbance of the skin in which 
there is a diminution in the number or volume of its constituents, 
the clastic tissue in particular; clinically, it manifests itself as a 
diminution of the actual thickness or consistence of the integument. 
The atrophic skin is therefore more supple, more easily folded and 
often thinner than the normal skin, its color is usually altered, 
either pinkish or of a pearly white. Sometimes, as in certain linear 
atrophies, for instance, the skin seems to he thickened on inspection, 
while remaining soft, depressible and easily folded; this depends 
upon its relaxation and infiltration by plasma, or upon the atrophied 
portion being pushed out, as it were, by the tension of the normal 
and more resistant integument of the vicinity (see Fig. 111). 

Cutaneous .sclerosis is a condensation of the skin-components, 
which may or may not be increased in size and number, but are 
always more heaped tip and move less readily over each other. 
The sclerotic skin may therefore be thickened or normal or even 
thinned; in the latter case it seems to be atrophic; but it is always 
more firm, less depressible, generally difficult to fold and often it is 
adherent to the subjacent tissues. 

Although atrophoderma and dermatosclerosis constitute different 
and in some respects opposite conditions, they are sometimes 
difficult to distinguish clinically; they are often combined or asso- 
ciated or follow one another, so that it is advisable to study the 
syndromes in which they are met with in the same chapter. 

Finally, there exist alterations of the skin which can hardly be 
designated otherwise than as cutaneous dystrophics. The integu- 
ment here is sometimes thinned, in other cases swollen, while its 
consistence is usually diminished. They form a natural group 
which logically takes its place by the side of the preceding. 

The pathogenesis of these atrophies, scleroses, and dystrophies is 
sometimes evident, often on the contrary very obscure and cer- 
tainly not uniform. Sometimes they arc congenital and represent 
actual malformations (example: atrophic nevi, xeroderma pigmen- 
tosum); in other cases they behave like degenerations due to old 
age, repeated exogenic or endogenic irritations; again, they are 
secondary to a more or less definite inflammatory or neoplastic 



SCLEROTIC AND ATROPHIC DERMATOSES 335 

process, of which they constitute a necessary or possible residue; 
or finally they seem to be primary or idiopathic, supervening with- 
out apparent cause and without being preceded by demonstrable 
lesions, so that their etiology and their mechanism altogether 
escape us. 

Sometimes a relation may be observed between the dermatosis 
and some disturbances of the general health, but this is entirely 
absent in other cases. 

Sclerotic and Atrophic Dermatoses. — The reasons for studying 
these together have just been stated. Practically, the two are 
inseparable. My object here is not to establish absolutely logical 
groups from the standpoint of general pathology, but to present 
clinical pictures conforming as closely as possible to actual facts. 

The atrophies and scleroses are deuteropathic or idiopathic. 

1. The deuteropathic, generally diffuse forms, with or without 
sclerotic retraction of the skin, following upon various grave 
dermatoses — pityriasis rubra of Hebra, malignant herpetides, con- 
genital pemphigus, some cases of pemphigus foliaceus — will not be 
commented on. The atrophy here is merely an epiphenomenon and 
the dermatoses in the course of which they occur have been described 
elsewhere (Chapters VI and X) . 

2. Other scleroses or atrophies, likewise deuteropathic, are 
entitled on the contrary to special consideration; they are sequelae 
of lesions or of circumscribed dermatoses, persisting long after the 
causative affection, which can sometimes be retrospectively recog- 
nized through them. These are the cicatrices and cicatricial atrophies. 

3. Next to them I place the linear or macular atrophies, a hetero- 
geneous group of atrophies of variable pathogenesis, comprising 
protopathic forms and others which are deuteropathic. 

4. A description of the idiopathic atrophies will follow. These 
curious and interesting affections are as yet imperfectly defined 
and their etiology is unknown. A distinction is made between 
diffuse or regional forms and other macular and disseminated forms. 

5. Congenital atrophies are very rare. A generalized form has 
been observed in degenerates, the offspring of parents tainted by 
alcoholism, tuberculosis, syphilis, etc. Their integument is thin, 
smooth, allowing the vessels of the hypoderm to shine through, 
pale or variably pigmented, and extremely vulnerable. Partial 
congenital atrophies, or atrophic nevi, are more or less distinctly 
outlined spots of the same appearance, or yellowish and prominent 
through hypertrophy of the hypoderm; they may assume a zoniform 
arrangement. 

6. I shall finally discuss the sclerodermas, diffuse and circum- 
scribed scleroses in the true sense of the term and which are still 
regarded as idiopathic. 



336 CUTANEOUS ATROPHIES, SCLEROSES AND DYSTROPHIES 

7. In another paragraph will be united a few regional dermato- 
scleroses which notwithstanding the analogy of their lesions, a 
mixture of atrophy and sclerosis, differ from each other by their 
localization, their course and probably by their pathogenesis. 

Cutaneous Dystrophics. — This denomination would fit a con- 
siderable number of chronic dermatoses: Cutaneous atrophies, 
scleroses and hypertrophies, many keratoses, dyschromias, folli- 
culosis, trichoses and onychoses, etc., really resulting from a nutri- 
tional disturbance of the tissues of the skin. I shall limit myself 
to grouping under this heading: xeroderma pigmentosum, senile de- 
generation, presenile dystrophy, and finally two rare degenerations: 
pseudo-xanthoma and colloid milium. 

CICATRICES. 

A cicatrix consists of newly developed tissue which has replaced 
a loss of substance or followed an inflammatory process. This 
new tissue is always fibrous; moreover, the reconstruction of the 
skin always remains imperfect for there is a lack of elastic tissue, 
smooth muscle fibers, hairs and cutaneous glands, often even of the 
papillary body. A cicatrix may therefore be said to be at the same 
time a deuteropathie dermatosclerosis and a cutaneous atrophy, 
even when the scar itself is hypertrophic. 

A good cicatrix is smooth, level or slightly depressed, pink or 
white in color, supple and movable on the underlying tissues. A 
vicious cicatrix is uneven, salient or furrowed by retracted bands; 
a keloid cicatrix is the seat of a prominent and hard fibrous hyper- 
trophy. 

Very superficial cicatrices are recognized only by a very trifling 
depression and a somewhat glistening sheen, with an altered "grain" 
of the skin, sometimes with dilatation of the follicular orifices; 
these changes being absent in simple macules. 

Thicker cicatrices are at first rose-colored, ultimately white or 
pigmented, sometimes scaly and usually firm on touch. Being less 
extensible, less elastic than the healthy skin and often provided 
with a less active blood supply, they are liable to become the seat 
of tears and cracks, or they may be so highly vulnerable that slight 
traumatisms may give rise to serous or hemorrhagic bullae or 
maintain ulcers in the scars; sometimes they are tender or even 
spontaneously painful. It is readily understood that when the 
causative lesions have involved the deep parts, bones, muscles, 
tendons, etc., the cicatrices may be adherent. 

The origin of cicatrices is extremely variable. From this view- 
point they may be divided into three groups: 

J. Those which are due to an artificial loss of substances, trauma- 



CICATRICES 337 

tism, wounds, accidental or surgical incision; a caustic agent, a 
burn, etc. 

2. Those which result from some ulceration. 

3. Those which are derived from an interstitial pathological 
process without apparent loss of substance, whose repair has given 
rise to sclerosis with a marked change in the structure of the skin. 
Between cicatrices of this kind and what I shall describe as cicatricial 
atrophies, it is not really possible to trace a distinct border-line. 

Although no cicatrix is strictly pathognomonic in itself, its prob- 
able origin can often be surmised; and scars being indelible consti- 
tute stigmata of special value. 

In estimating the symptomatic significance of cicatrices, it is 
necessary to keep in mind especially their extent, their number 
(variola, acne), their configuration (syphilis, tuberculosis), their 
seat (bubos, chancroids, chancres, lupus, etc.), their depth (ulcers, 
etc.), and even their color (favus, syphilis, etc.). It must be remem- 
bered, however, that their features may be modified by various 
accessory factors, superadded infections, faulty dressings and an 
unfavorable general, regional or local territory. 

Among the pustular and ulcerative affections which leave 
cicatrices, I shall mention variola, ecthyma, pustular acne, acne 
necrotica, furuncle, carbuncle, ulcerative zona, soft chancre; the mul- 
tiplicity of cicatrices of this type, their small extent and their locali- 
zation are more or less plainly characteristic. 

All tubercles, syphilitic, tuberculous or leprous, are almost neces- 
sarily followed by cicatrices; and this fact is implied in the definition 
of these lesions as non-resolutive. 

For simplicity's sake, I shall proceed to sum up the features of the 
cicatrices caused by these three great infections, independently of 
the original lesion. 

In syphilis, the chancre leaves a cicatrix only when it has ulcer- 
ated; actually, in nearly one-half of the cases. 

Ulcerative secondary syphilides may spatter the integument with 
more or less deep, flat or honeycombed cicatrices, often with a 
pigmented border. 

The cicatrices of ulcerative or gummous tertiary syphilides are 
said to be characteristic on account of their white and smooth 
appearance with a zone of peripheral pigmentation. In reality, it 
is their configuration and arrangement which are of special diag- 
nostic value; they generally have sharp and regular contours, 
orbicular or semicircular, or are made up of disks arranged in arcades, 
or of reniform polycyclic patches. The cicatrices of tubercular 
syphilides are often of irregular surface, honeycombed, purplish 
or brownish, checkered with white stars. 

The presence of round and very superficial cicatrices on the 
22 



338 CUTANEOUS ATROPHIES, SCLEROSES AND DYSTROPHIES 

buttocks may be cited in favor of n diagnosis of congenital syphilis; 
but their value would lie very small in the absence of other stigmata. 
Radiating cicatrices of the lips are on the contrary very charac- 
teristic in themselves. 

The cicatrices of ulcerated tuberculosis, bony, articular or glan- 
dular, as well as those <»f tuberculous gummas and ulcers, are often 
distinguished by their irregular, sinuous and eroded contours, and 
their uneven surface, which presents retracted strands, promon- 
tories and bridges. The latter — consisting of minute strands ad- 
herent only by their extremities (under which horny scales, colored 
black by dust, accumulate) and which can he raised by slipping 
a pin underneath possess, I believe a real diagnostic value for 
tuberculosis; but they are not absolutely pathognomonic, for I have 
-ecu "bridged" cicatrices as a sequel of sporotrichotic lesions, of 
carbuncle in a diabetic patient, etc. 

Lupus leaves very variable cicatrices, according to its varieties; 
flat, white and smooth in its erythematous resolving form; thicker, 
often rose-red, sometimes vicious and keloidal, in the deep forms. 
They may cause serious deformities of the orifices of the face, for 
example ectropion, stricture or atresia of the nares and the mouth; 
adhesions of the fingers or toes (Fiji - . 170), contractions of the joints, 
etc. They are frequently the seat of renewed growth of lupus 
nodules. 

Leprosy furnishes very variable cicatrices, superficial or deep, 
supple or very sclerotic, prominent or depressed, following upon 
bullae, leprides and especially upon tubercles and infiltrations; 
they are often described as morphoea leprosa; they are white, or 
sometimes deeply pigmented and are characterized by their anes- 
thesia. Aside from these morpheas, mention must be made of the 
deep cicatrices left by the ulcers of leprosy and the diffuse dermato- 
<clerosis of the extremities in the mutilating form 

The vegetative dermatoses — such as, Oriental boil, yaws, pem- 
phigus vegetans, iodide and bromide eruptions, etc. — also leave 
cicatrices, often irregular, with pigmented borders. Needless to 
say, this is likewise true for ulcers of all kinds, phagedenas, ^an- 
grenes; the scars which follow depend in the extent, configuration 
and depth of the original lesions. 

The same remark applies to tumors, which may give rise to 
cicatrice-, benign tumors like certain nevi mollusci or absorptive 
angiomas and malignant epitheliomatous tumors. In this way, 
secondary carcinomas of the skin, ulcerated or not, of the type 
formerly named scirrhus, become the seat of a fibrous thickening 
which appears exactly like a lardaceous scleroderma. Finally, in 
cutaneous epithelioma of the variety known as flat cicatricial epi- 
thelioma, the center of the patch is often seen to become sclerotic, 



CICATRICES 339 

the epithelial newformation remaining demonstrable only at the 
borders in the form of a narrow beaded margin. 

It is useful to know that vice versa cicatrices may become the 
starting-point of epithelioma which is generally of the lobulated 
type. 

The diagnosis of the origin of cicatrices is often greatly helped 
by the history, by serodiagnosis and by the general examination of 
the patient. 

Cicatricial Atrophies. — Alongside of these often irregular and im- 
portant cicatrices which have just been discussed, must be placed 
more discrete, usually macular lesions, of atrophic appearance in 
the clinical sense of the word. The name of cicatricial atrophies is 
reserved for these lesions. 

Cicatricial atrophy, generally in the form of white, flat, smooth, 
more or less indurated patches, is the inevitable result of lupus ery- 
thematodes discoides, the different forms of depilating folliculitides, 
and Brocq's pseudo-alopecia; of the resolutive tuberculous lupus; 
tubercular syphilides and the majority of non-ulcerating lepromas. 

It characterizes a variety of lichen, known as lichen planus 
atrophicus. 

Several bullous affections, notably pemphigus congenitalis, leprous 
pemphigus, rarely Duhring's disease, leave spots or patches of 
thinned skin, often pigmented or purplish, somewhat indistinctly 
outlined. 

Small atrophic and leukodermic spots, associated with pigmenta- 
tions, are noted in various dystrophies, such as xeroderma pigmen- 
tosum, senile degeneration, etc. 

Keratosis pilaris, on healing, leaves behind it a crop of punctiform 
cicatrices, the site of which is typical. 

Favus very often produces large, smooth, bald and cicatricial 
surfaces, usually of a pinkish color, but sometimes decidedly white. 

Mention must also be made of radiodermatitis, which even in the 
absence of ulceration, may be followed by white cicatricial atrophies 
with diffuse borders, mottled by telangiectases and pigmentary 
spots. 

The fact that certain erythematous dermatoses terminate in 
cicatricial atrophy, led Unna to establish his group of ulerythema 
(from ov\t] = cicatrix), comprising a centrifugal type, lupus erythe- 
matodes, and ophryogenic and sycosiform types. 

This atrophy-producing tendency belongs also to certain erythe- 
matous tuberculides. Finally, some special cases of erythema, 
urticaria and purpura, have been known to terminate in cicatricial 
atrophies, which have been compared with the idiopathic macular 
atrophies. 

The diagnosis of the origin and nature of these cicatricial atrophies 



340 CUTANEOUS ATROPHIES, SCLEROSES AND DYSTROPHIES 

generally rests upon their form, their dimensions, their number, their 
topographical seat; sometimes, it has been possible to follow their 
development, or the original lesions can be discovered, either at the 
circumference of the spots or elsewhere. 

Summarizing, the clinician when confronted with an atrophic or 
sclerotic spot must think in the first place of a cicatrix and inquire 
as to its origin; next, if there is no genuine cicatrix, he must think 
of the cicatricial atrophies; the processes which may terminate 
in a lesion of this nature have just been shown to be extremely 
numerous and different; all possible theories should be reviewed; 
third, when all the preceding conditions can be excluded, it is justi- 
fiable to assume an idiopathic macular atrophy. 

Pathological Anatomy. — The pathological anatomy of cicatrices 
varies according to the depth and character of the lesions which 
have caused them. The cutis, or at least the papillary body, must 
have been involved, for otherwise repair would have occurred with- 
out a scar. 

In a general way, their structure is as follows: the epidermis is 
more or less thick, often hyperkeratotic or parakeratotic, smooth, 
or sends out a few irregular proliferations at its deep aspect, it covers 
a dense fibrous tissue, composed of parallel connective-tissue bundles, 
deprived of elastic fibers or at least of a regular elastic network. 

The papilla? and the entire papillary body are often missing. 
In the spaces between the fibrous tissue rows of embryonic or 
plasma cells and often very numerous mast-cells persist for a long 
time. The vessels, relatively scanty, but often telangiectatic under 
the epidermis, follow variable paths, having nothing in common 
with the normal vascular distribution. Not infrequently, there are 
collections of pigment in the gaps of the fibrous tissue adjacent to 
the epidermis, in the area or at the circumference of the cicatrix; 
more rarely, pigment is noted in the epidermis itself. 

The hairs and pilosebaceous follicles, as w r ell as the sweat-glands, 
are absent or sometimes transformed into milium cysts. 

Treatment. — Cicatrices may, in the course of time, become flexible 
and resume a nearly normal color; but they are never entirely 
obliterated. 

The prophylactic treatment of vicious cicatrices consists in the 
use of proper dressings, autoplastic operations: the so-called 
epidermic grafts of Reverdin, or dermo-epidermic grafts of Ollier- 
Thiersch, or the small deep skin grafts of American writers may be 
indicated in cases of extensive loss of substance. 

Sometimes, when circumstances are favorable, it may be advan- 
tageous to excise a disfiguring cicatrix, in order to replace it by a 
less evident linear scar. Local massage, sometimes scarifications, 
often the application of mercurial ointments or radiotherapy, may 



LINEAR AND MACULAR ATROPHIES 341 

improve an unsightly cicatrix. Injections of thiosinamin or fibrol- 
ysin are not devoid of danger and yield few durable results. As 
regards keloids, this subject will be discussed further on. 

By means of ionization of a solution of potassium iodide on the 
negative electrode, it is possible to liberate, make supple and bleach 
vicious cicatrices, even in longstanding cases (Chiray and Bour- 
guignon.) 

LINEAR AND MACULAR ATROPHIES. 

Linear atrophies — called- "vergetures" in French, from their 
resemblance to the livid streaks left on the skin by blows with a 
strap or rod — are also known as stria? atrophica?, stria? gravidarum, 
striee distensa?, etc. 

These are cutaneous atrophies of elongated form, prominent, 
level or depressed, but always soft and indentable — which seem to 
to be due to overstretching of the skin ; they are indelible, but often 
become less visible in the course of time. 

Linear atrophies have a length of one to several centimeters, a 
width of 1 to 10 mm., or more, their form is elongated, spindle- 
shaped and often undulating. Their color, of a dusky or bluish red 
when they are recent, frequently passes into a pearly white; some- 
times, on the contrary, they are brownish. Their borders are dis- 
tinct; their surface is smooth, or puckered, or designed in large 
lozenges; on touch they give a sensation of softness, of relative 
emptiness; as if a very thin skin were resting on a soft and yielding 
tissue. 

Almost invariably multiple and usually symmetrical, these linear 
atrophies may develop in many regions, principally on the abdomen, 
but also on the thighs, the loins, above the knees, on the flanks, the 
breasts, the buttocks, etc. Their direction corresponds as a rule to 
what are known as the lines of cleavage of the skin ; their long axis 
is perpendicular to the direction in which the maximum tension 
which seems to have caused them has taken place ; they are usually 
vertical on the abdomen, the trochanteric and deltoid regions; 
transverse on the flanks, the loins and above the patella; radiating 
on the breasts. 

Linear atrophies are much more common in women, even outside 
of pregnancy (36 in 100 cases in adult women, against 6 per cent, 
in men, according to Schultze); although pregnancy is the most 
common cause. They are observed in nine-tenths of all pregnant 
women though some women never acquire them, even after ten to 
fifteen confinements. Among other frequent causes of linear atrophies 
must be mentioned obesity and typhoid fever. 

In an endeavor to ascribe a mechanical pathogenesis to these 
lesions — a gradual or a rapid distention of the skin which pla} T s an 



342 CUTANEOUS ATROPHIES, SCLEROSES AND DYSTROPHIES 

evident but not exclusive part in their production attention has 
been called to the effects of growth, anasarca, voluminous tumors, 
or traumatisms. 

It is certain, however, that another mechanism intervenes aside 

from this distention. As a matter of fact, linear atrophies may be 
absent in eases of enormous aseites or very large hernias; in all 
probability, there is no actual distention of the skin in corpulent or 
in rapidly growing individuals; linear atrophies may occur even as ;i 
sequel of emaciation, in typhoid fever, tuberculosis, other severe 
infections and certain nervous diseases.* I have seen linear atrophies 
and postsyphilitic atrophies coexisting in the patient shown in Fig. 
Ill, who had lost weight, from ION to 72 kilos. There is accord- 
ingly reason to suspect, in affected individuals, the existence of a 
special delicacy of the skin, notably its elastic tissue, either of 
congenita] or toxi-infectious origin. 

The pathological anatomy of linear atrophies sufficiently explains 
their clinical features. The epidermis and the papillary body 
are spread out or folded, the connective-tissue bundles of the 
cutis are parallel and atrophied. 

The fundamental lesion consists of the disappearance of the 
elastic tissue network, the retracted and shrivelled stumps of which 
are seen on either side of the lesion; it is noteworthy that this 
rupture is not accompanied by a demonstrable degeneration, such 
as a transformation in elacin of Unna, etc. 

Linear atrophies show no tendency to repair. No treatment can 
guarantee their disappearance, although they may be rendered less 
apparent by hygiene, hydrotherapy, tonics. It is doubtful if sup- 
porting appliances, pregnancy belts and so forth, are of any use as 
preventives, but their employment should nevertheless not be 
neglected. 

Round or Macular Atrophies. — This name, as well as macules 
atrophica or postsyphilitic atrophies, designates lesions which are 
entirely analogous, except in form, with linear atrophies. These 
spots are depressed, level, or prominent, smooth, shrivelled, or 
pitted, according to the state of tension or relaxation of the skin, 
lavender or white according to their age and always very soft and 
depressible. They are round or oval, punctiform or lenticular and 
are scattered without order, usually in large numbers on the flanks, 
the chest, the back, or the shoulders ( Fig. 111). 

The relation of round atrophies to syphilis is undoubted; they 
belong to the secondary stage, sometimes associated with an erup- 
tion of papular syphilides or with the pigmented syphilide of the 
neck. Their development could sometimes be followed as a sequel 
and at the site of lenticular papules. There are cases, however, in 
which the preexistenee of lenticular papules, or even of roseolar 



1D10PA THIC A TROPHIES 



:;i: 



spots, at the atrophic points cannot be demonstrated and is posi- 
tively denied by the patient. 

The structure is the same as that of linear atrophies and the 
treatment is equally futile. 




Fig. 111. — Round syphilitic atrophies of the dorso-lumbar region; their elevation, 
very apparent in extension of the trunk, entirely disappeared when the trunk was 
flexed or the skin stretched. The patient showed, in addition, linear atrophies on the 
abdomen and the hips. 

IDIOPATHIC ATROPHIES. 

The qualification "idiopathic," it is needless to state, merely 
expresses our ignorance as to the underlying causes. In regard to 
the pathogenesis of these atrophies, although they may sometimes 
appear primary, they are generally supposed to be the result of a 
preliminary or concomitant inflammatory process. Cases can be 
distinguished in which this process is clinically evident and others 
in which it is not demonstrable ; but it is probable that even in the 
latter an inflammation is present in the first stages of the affection 
and could be revealed by histological examination. On this view 
are based the terms dermatitis atrophicans, erythema atrophicans, 
etc., which have been suggested. It can by no means be claimed 
that the group of idiopathic atrophies presents a unit, the contrary 
being probably true. However that may be, from the morphological 
point of view, they may be divided into two groups, according to 
their being diffuse or circumscribed. 

1 . Diffuse Idiopathic Atrophies. — The first observations were made 
by Buchwald (1883), Touton and Pospelow. Ten years later, F. J 
Pick described a type of this affection under the name of erythro- 



344 CUTANEOUS ATROPHIES, SCLEROSES AND DYSTROPHIES 

melia and Herxheimer in his turn, with Hartmann, resumed its 
study, under the name of acrodermatitis atrophicans chronica. The 
affection is progressive and develops in interrupted attacks; but in 
the cases of Kaposi and of Colombini its course was rapid. Its 
seal of predilection is the limbs, but it may reach also, or inde- 
pendently, various regions of the trunk, the hips and even the 
head. The most distinctly marked clinical type is described in the 
following: 

Erythromelia of Pick, or acrodermatitis chronica atrophicans of 
Herxheimer.— In this form the dermatosis attacks first the extremi- 
ties, more particularly the dorsal aspect of the hands and feet and the 
extensor surfaces of the elbows and knees. It sometimes seems to 
progress from the periphery toward the center, but usually settles 
or markedly predominates in the above enumerated regions. The 
thighs and arms are rarely involved, the shoulders and hips only 
exceptionally. 

The lesion consists of an atrophy which may seem primary; in 
other cases, it is preceded by a red edematous infiltration of firm 
consistence; from the hands and feet, this sclero-edematous infil- 
tration, which deforms the fingers and toes and impedes their move- 
ments, may invade the forearms and legs, often in the form of a 
pre-ulnar and pre-tibial band with redness in the vicinity. 

The atrophy, primary or following this inflammatory stage, is 
red or rose-colored, slowly extensive and permanent. The thinned- 
out skin, through which can be plainly seen the venous network and 
the tendons, is nearly alopecic, slightly squamous and puckers like 
tissue-paper; on touch, it gives an impression of softness, like that 
of moist chamois-skin. 

Histology shows, aside from a diminution of the elastic plexus, an 
edematous and cellular infiltration containing numerous plasmocytes. 

Erythromelia more frequently attacks men of mature age than 
women. It lasts for years. Its ultimate state is not known; perhaps 
a few cases terminate in recovery. 

When it is limited to the hands, it might be confused with pella- 
grous erythema; or in its very extensive diffuse form, with senile 
atrophy. The presence of an edematous inflammatory infiltration 
at certain points suffices for the avoidance of these errors. Redness 
and atrophy serve to differentiate erythromelia from scleroderma 
at the onset, where the fingers are likewise stiff and infiltrated; but 
there are eases in which the two processes are combined. 

In the poikiloderma vascularis atrophicans of Jacobi (190!)), or 
reticular atrophy of Zinsser, the plexiform atrophoderma is com- 
bined with telangiectasis and pigmentation. 

2. Macular Idiopathic Atrophies. — This second group of cases was 
established about the same time and parallel with the first, although 



IDIOPATHIC ATROPHIES 345 

with less certainty. A few old cases of cyanotic macules (Besnier 
and Founder) and of erythematous atrophy in patches with periph- 
eral extension, etc., were known; but this clinical type had no 
scientific standing until the publication (1891) of Jadassohn's case 
of anetoderma erythematosum, or atrophia maculosa cutis. 

Galewski, Nielsen, Heuss and others have contributed case- 
reports; the observation of Thibierge (erythematous atropho- 
derma) approaches it in certain respects, while also offering points 
of contact with lupus erythematodes. But the cases of Pellizari 
(urticarial erythema), Balzer (erythema polymorphe atrophicans), 
Hallopeau (chronic urticaria with cicatrices), Pospelow (purpura 
atrophicans), Nikolsky, etc., must according to Heuss be trans- 
ferred from the group of idiopathic macular atrophies to that of 
cicatricial atrophies. 

It has been asserted that macular atrophy represents merely a 
special case, a circumscribed form, of idiopathic atrophy. Certain 
observations, due to Herxheimer, Thimm and others, seem to 
establish a transition between the two classes. The objective 
differences are, however, as a rule, very marked, as appears from 
the following description. 

Macular Atrophy or Anetoderma Erythematosum of Jadassohn. — 
There is a scattered, more or less profuse eruption of atrophic spots, 
sometimes predominating on the extensive surface of the limbs, on 
the flanks and on the back. Most commonly, they are nummular 
and rounded, sometimes irregular or even in strise; their color varies 
from purplish red to pearly white; their contours are distinctly 
marked by the difference in color and by the depression of the 
skin at their site; on the least movement, the epidermis on their 
surface becomes folded. The integument as a whole has a very 
peculiar doughy and soft consistence; on touch, the spots convey 
the impression of holes dug in the skin; their flabbiness contrasts 
with the firm consistence of the atropho-sclerotic spots described in 
the next section. 

Jadassohn believes he has shown that at the onset the lesion 
is a dermic papule analogous to a syphilitic papule; others have 
seen spots appearing atrophic from the start. They progress slowly 
for several weeks or several months ; sometimes a rose-colored circle 
marks the zone of invasion; it is said that some spots may completely 
disappear. 

Nearly all the reported cases were observed in young females who 
often were tainted with tuberculosis. 

The differential diagnosis must be made from nevi atrophici, 
from cicatrices and from cicatricial atrophies. I have observed spots 
of identical appearance in Recklinghausen's disease, the true char- 
acter of which could onlv be established bv histological examination. 



346 CI TANEOVS ATROPHIES, SCLEROSES AND DYSTROPHIES 



SCLEROTIC ATROPHIES IN SPOTS. 

In juxtaposition to the soft macular atrophy, or anetoderma, a 

place must be assigned to a clinical picture to which attention has 
been drawn by many recent publications. It consists of both atrophic 

and sclerotic spots, of a glistening, pearly or porcelain white, level 
or slightly depressed, firm on touch, which appear in variable number 
in certain regions. Their dimensions vary in the same case from a 
pin-head to a silver quarter, hut they may become confluent in 
larger >pots. 

It is more than probable that this syndrome docs not constitute 
a single affection. American and English writers designate it under 
the name of White spot disease, first employed in 1903 by Johnston 
and Sherwell. It may he brought about either by lichen planus 
scleroticus or by morphea guttata. In a given case, an effort must 
he made to differentiate between these two affections, on the basis 
of what will follow. This is often impossible and the question then 
arises if there is not another pathological entity of nearly identical 
appearance. 

Lichen planus scleroticus vel atrophicus (Fig. 35) is met with in 
both sexes and may be situated in any region of the body, but 
especially at the nape of the neck and on the wrists; the small white 
spots, finely criss-crossed, not frequently studded with horny plugs, 
may have a slightly raised border; they begin as polygonal papules 
of tawny hue and accordingly represent cicatricial atrophies. When 
there is a coexisting ordinary lichen planus on the integument or 
on the buccal mucosa, this of course settles the diagnosis. The 
histology of the lesions shows a small patch of subepidermic sclerotic 
atrophy, under which may be found, in recent lesions, a remnant of 
the circumscribed cellular infiltration belonging to lichen planus. 
The lichen albus of Zumbrusch, be it stated, is nothing other than 
this sclerotic lichen planus. 

Morphcea guttata, or superficial circumscribed scleroderma, or parch- 
ment-like scleroderma ( "Kartenblattaehnliche morphoea," of Unna) 
or white-spot disease, properly so called, is observed rather in young- 
girls or women of any age, more or less tainted with tuberculosis; 
its seat of predilection is on the upper chest, the shoulders, the 
neck, the nape of the neck and the perigenital region. The lesions 
which arc lenticular or nummular with a tendency to depression, 
are of a pearly or porcelain-white color and are bordered by a 
narrow pink or purplish /one; they may bear a few thinly scattered 
horny plugs; the sclero-atrophic spots originate under this form and 
may in all probability disappear; their number is very variable. 

The condition represents a slight hyperkeratosis, with a patch 
of compact thickening in the cutis of modified staining capacity, 



SCLERODERMA 347 

poor in cellular elements; the preliminary pathological process is 
unknown. 

Several cases of white spots coexisting with scleroderma in patches 
or in bands have been published; however, the relationship between 
these two affections is not certain for all the cases, some authors 
have thought of a relation with lupus erythematodes. 

Treatment by means of radiotherapy, electrolysis and thyroid 
extracts, seemed to be beneficial in several cases. 



SCLERODERMA. 

In the very extensive realm of the dermatoscleroses, the sclero- 
dermata form a limited group which comprises apparently idiopathic 
affections, meaning that their nature is entirely unknown. They are 
divided into four groups : 

Sclerema Neonatorum. — A child, born apparently quite healthy, 
may present at the end of a few hours, or after two to ten days, 
sometimes still later, a progressive induration of the integument, 
constituting sclerema. 

The affection, which is very rare, begins at the posterior portion 
of the lower limbs, reaching the loins, the back and the entire body ; 
it may also begin in the face. 

The skin, of a yellowish, livid, or lilac white, is not depressible 
with the finger, as in edema, but firm and cannot be folded. Move- 
ments are impeded, the infant is unable to take the breast, emacia- 
tion is rapid, respiration is interfered with, the pulse is slowed and 
death is apt to supervene in three or four days, almost invariably 
with hypothermia or in convulsions. 

This disease, which presents the behavior of an infectious process 
of indefinite character, differs altogether from congenital generalized 
cutaneous atrophy. It has likewise nothing in common with fetal 
ichthyosis, in which the integument is red, tense and covered with a 
carapace of scales. 

For the treatment of sclerema, the children must be kept warm in 
the incubator and fed with a stomach-tube, if necessary. Cures 
have been observed to follow mercurial inunctions. 

Generalized Scleroderma. — This disease, also named edematous 
scleroderma (A. Hardy), or sclerema of adults, or sclerema (Besnier), 
manifests itself in two forms: 

In the acute form, the onset is sudden and the course is rapid. 
The patient complains of stiffness, impairment of movements of the 
trunk and limbs; breathing becomes difficult, the integument be- 
comes thickened and diffusely indurated. This form is very rare 
and often fatal in a few weeks, or at most a few months. 

The slow form,, likewise uncommon, is preceded by prodromata: 



348 CUTANEOUS ATROPHIES, SCLEROSES AND DYSTROPHIES 

disturbances of the general health, emaciation, febrile attacks, 
neuralgias and arthralgias, stiffening of the limits, heat and itching 
in various portions of the skin, sometimes with erythema, or local 
syncope, or edema, or secretory disturbances, hyperidrosis and so 

forth. 

Next follows a sclero-edematoiis period, during which the integu- 
ment of the entire body and the limits or of extensive areas becomes 
thickened, infiltrated with a sort of lardaceous, non-depressible 
edema, with adhesion to the subjacent tissues; so that it is indurated, 
tense and cannot be folded. The color is a yellowish white, inter- 
spersed with gray or brown or lilac spots. The face becomes like 
marble, its folds disappear, movements of the eyelids, forehead and 
lips become impossible; speech and the ingestion of food are ham- 
pered. The induration of the neck and the chest interfere with 
respiration, sometimes with swallowing. The limbs are stiff or 
actually immobilized, more seriously affected in their first segments 
than at the extremities. The boundaries of the affected regions are 
always diffuse. 

The sclero-atrophic period gradually follows upon the preceding, 
usually after a few months. The skin becomes fibrous, retracted, and 
adherent to the muscles and the bones; the subcutaneous panni- 
culus disappears; the muscles are themselves sclerotic and move- 
ments are furthermore impeded by fibrous bands. The mucous 
membranes may be involved. The patients are enormously incon- 
venienced by the cuirass in which they are enclosed and they com- 
plain of persistent cold; sensibility is preserved. 

Sclerema supervenes as the sequel of a fall into cold water, a severe 
traumatism, or an infectious disease. Its course is in attacks, with 
remissions; death results most commonly from pulmonary, digestive 
or renal complications, or through cachexia. 

Progressive Scleroderma, Sclerodactylia.— The onset here is on 
the upper extremities, rarely in the face. This form is systematized, 
symmetrical and progressive. 

The first symptoms consist of nervous and vascular disturbances, 
numbness, sensations of cold, spasms, shooting pains, local asphyxia 
or local syncope; they occur in attacks, as in Raynaud's disease, 
or may be constant; occasionally hyperidrosis or pemphigoid bullae 
have been noted. These phenomena may be continued during 
months and years. Asphyxia of the nose and ears, and paresthesias 
of the face, have also been observed. 

In the fully developed stage, which supervenes at the end of several 
months or years, the fingers become pointed, their skin is thinned 
and adherent to the bones; they appear hard and dry, can no longer 
be flexed or extended and are of a grayish or slightly livid color. 
The process begins at the last phalanges, reaching the root of the 



SCLERODERMA 



349 



fingers, the hands, the forearms, etc. The fingers transformed into 
rigid fusiform sticks may become the seat of sluggish ulcers or of 
gangrenes, or bony disintegration; terminating in mutilations like 
those of leprosy. The nails are raised, thinned, or onychogry photic. 
The hypoderm, the muscles and tendons participate in the sclerotic 
induration, thereby leading to a real mummification. 

Entirely analogous, although usually less pronounced alterations 
occur in the lower extremities (Fig. 112), the toes become turned out- 




Fig. 112. — Progressive scleroderma. 



ward; ulcerations and a certain degree of plantar keratoderma 
are not uncommon. 

In the face, the appearance is characteristic; even more so than 
in generalized scleroderma. 

The wrinkles and folds are obliterated, the features are fixed and 
immovable; the ears are rigid, the nose is pointed, the lips are thin 
and tense, the eyelids cannot be completely closed, mastication and 
deglutition are impeded; the tongue may become atrophied. I 
have seen aphonia resulting from an involvement of the larynx. The 
neck, the chest and the entire thorax are finally affected and, to a 
less degree, the thighs and the abdomen. 

Abnormal 'pigmentations, often occurring early, form an integral 



351 » ' UTANEOl s A TROPHIES, Si 'LEROSES AND DYSTROPHIES 

part of the picture; they are sometimes diffuse and limited to the 
sclerotic portions, often much more extensive, macular, mottled or 
plexiform. 

In a few rare east's, the production of subcutaneous calcareous 
concretions has been noted, appearing primarily and predomi- 
nantly on the fingers (Thibierge and Weissenbach, 1 * > 1 1 ). [A unique 
case of cutaneous ossification in scleroderma has been recorded by 
Pollitzer, 1917.] 

The course is slow, interrupted by remissions; death is the result 
of complications or of cachexia; it may occur suddenly. 

Atypical cases have been noted, beginning with sclero-edema and 
accompanied by erythema. The association of sclero-edema in patches 
with sclerodactylia has also been observed. The diagnosis of the 
clinical form may present some difficulties on account of these trans- 
itions which, moreover, justify the classification of all sclerodermas 
in a single group. 

The differential diagnosis from Raynaud's disease may be impos- 
sible at the onset; although sclerosis of the skin is not the initial 
and dominating feature of this condition, there occur true mixed or 
intermediate cases. 

Lepra nervorum is characterized by anesthesia, muscular atrophy 
and thickening of the nerves. 

In syringomyelia, there exists a dissociation of sensibility, but no 
true sclerosis. A confusion with progressive arthritis deformans 
could be due only to faulty observation; the stiffness and the deform- 
ity of the fingers in this case are not referable to the condition of the 
>kin, which is thinned but remains normal. Association is, however, 
possible and has been demonstrated. 

The frequent pigmentations of scleroderma should be kept in 
mind in order to avoid confusion with other melanodermas. 

Partial Sclerodermas. — The sclerotic lesions may be circumscribed, 
either in patches with well defined contours, or in bands and in rings. 

Scleroderma in Patches. The patches of scleroderma, also known 
;i- morphea, differ from cicatrices by their spontaneous and primary 
appearance as well as by their course. They are distinguished 
from the macular atrophies by their sclerotic character. 

Morphea begins as a more or less thickened and indurated, 
lilac or purplish >pot. which slowly increases in size; at the end of a 
\\'\v weeks or months its center becomes whitened and indurated, 
often through confluence of originally isolated sclerotic points. 
According as the patch is level, infiltrated, or mammillated, a dis- 
tinction is made between morpheas alha plana, lardacea and tuberosa; 
hut the appearance may change in the course of development. I 
have described above under Morphaa guttata, white-spot disease 

the form in which the induration resembles parchment and i> 
merely superficial. 



SCLERODERMA 351 

The patches of morphea have a variable extent, from 1 to 20 
cm., or larger; an oval or irregular shape, with convex or sinuous 
borders; of a glistening, pearly, bluish, or wax-white color. They 
are sometimes spotted with pigment, or mottled with telangiectases, 
or they may desquamate in large shreds. Their most characteristic 
feature is that they are usually bordered by a zone of mauve, pur- 
plish or tawny color, several millimeters in width, constituting the 
lilac ring of authors. The consistence of the patches is hard, even 
woody; they cannot be folded; sometimes they are more or less 
closely adherent to the subjacent layers, the bones and the muscles. 

On these patches the hairs have fallen out, the secretions are 
absent, sensibility is lessened in proportion to the degree of the 
sclerosis; at the onset, tickling and itching sensations have been 
noted. 

Morphea spots may be single or multiple, sometimes symmet- 
rical and occupy any region of the body. They are not uncommon 
in the face. On the hairy scalp, confusion must be guarded against 
with the cicatrices from lupus erythematodes or other causes. On 
the chest, they must not be confused with scirrhus cancer. They 
are also seen on the abdomen, often on the limbs and even on the 
buccal mucosa; in the last named location, they assume the shape 
of hard white spots, which are retracted, in contradistinction to 
leukoplakia. 

The patches of morphea after remaining stationary sometimes 
for a very long time, may begin to spread; or they may give rise 
to obstinate ulcers at points exposed to injury. Most commonly, 
they finally undergo retrogressive changes, the lilac ring disappears, 
the extent of the patch narrows, its center shrivels, becomes supple 
and covered with superficial telangiectasis. A localized atrophy 
is left behind, known as morphea atrophica. It is said that total 
disappearance may occur. 

Scleroderma in Bands. — Instead of patches, the sclerosis may 
form bands, 2 to 5 cm. wide, with broadening and narrowing here 
and there. Their length is variable; they may extend, for instance, 
from the shoulder to the hand, or from the pelvis to the heel. The 
sclerotic band is prominent or level, or depressed as a groove, and 
may impede movements. The lilac ring is rarely complete. 

A relatively not uncommon clinical type (numerous cases of which 
were presented at the London International Congress, 1896) is 
is that of frontal scleroderma; a white or brownish depressed 
sclerotic band, starting from around the superior orbital foramen, 
passes across the forehead, like a sabre-stroke, terminating more or 
less close to the fontanelle. 

A possible relation of the course of sclerodermatic bands with the 
nervous, radicular, etc., territories has been pointed out; but these 
relations are irregular and very inconstant (see linear nevi, p. 206). 



352 CUTANEOUS ATROPHIES, SCLEROSES AND DYSTROPHIES 

Annular Sclerodermas.- In exceptional cases, a band of sclero- 
derma has been seen to hollow an annular or semiannnlar groove 
around a limb or around a finger. The stricture may produce 
edema and elephantiasis below it. 

Analogous appearances may he produced by two other affections, 
positively distinct from annular scleroderma. 

One of these is ainhum, of Da Silva Lima — or spontaneous 
amputation of the toes — which is endemic in several colored races 
and begins in adult life, almost invariably at the little toe, which it 
strangles and finally separates. 

The other, known as congenital amputations, is observed in all 
races, affects the limbs at any level and is attributed to an intra- 
uterine constriction by amniotic bands. Separation is incipient at 
birth and may become complete in a few weeks or years. 

Pathological Anatomy. -The lesions of scleroderma, no matter of 
what clinical form, consist of a thickening with partial disappear- 
ance or sometimes a degeneration of the connective-tissue bundles; 
the elastic fiber plexus is preserved and appears increased as the 
result of close approximation of the fibers. It is not known if this 
fundamental lesion is the outcome of an always identical process. 

In recent cases of generalized scleroderma and scleroderma in 
patches, I have demonstrated a subacute, predominantly peri- 
vascular inflammation and a newformation of connective tissue. 
The smooth muscles may be hypertrophied. The vessels were almost 
invariably found to be affected by endoperiarteritis and phlebo- 
sclerosis; the peripheral nerves are slightly involved, or their sheath 
i- thickened. 

The papillary body is flattened and obliterated, the epidermis is 
often atrophied; the horny layer is increased. The follicles and 
glands disappear. Sclerosis of the hypoderm and of the muscles has 
been described, with inflammation of the periosteum and rarefac- 
tion of the bony substance; incongruous lesions, of doubtful signifi- 
cance, are found in the nerve centers. 

In a case of generalized scleroderma, of hyperacute onset, observed 
by Thibierge, I found the following changes: in the sclerematous 
Stage, ;i thickened epidermis, a tendency to obliteration of the 
papilla?, a condensation of the papillary body where the elastic 
plexus was irregular and ravelled; in the stage of sclerotic atrophy, 
a thinned epidermis apparently glued to the corium, disappearance 
of the papillae, a narrow and sclerotic papillary body supplied with 
several layers of elastic fibers parallel with the surface; no sign of a 
cellular infiltration. 

Etiology and Pathogenesis. Scleroderma is more common in the 
female sex. The diffuse forms are met with especially between 
twenty and forty years, the partial forms, at uuy age. 



REGIONAL ATROPHIES AND DERMATOSCLEROSES 353 

Sudden exposure to cold, violent emotions, overexertion, men- 
strual disturbances, are frequently held responsible; the probable 
action of traumatism has been pointed out for the localized and even 
for the generalized forms. It seems that several infections may 
play a part, especially acute rheumatism, typhoid fever, etc., 
perhaps tuberculosis or congenital syphilis. In a general way, very 
little is known concerning the etiology of the sclerodermas. 

The pathogenesis is equally uncertain. Vascular lesions are prac- 
tically sure to occur. The effect of a trophic or angioneurotic 
nervous disturbance has been suspected, on account of the arrange- 
ment of certain sclerodermas in bands and the common nervous 
antecedents of these patients. Cases where sclerodermas super- 
vened in the course or as a sequel of exophthalmic goitre have given 
rise to the thyroid and polyglandular theory. Various infections or 
toxic influences possibly act upon the nervous system and the 
vascular apparatus, through the intermediation of functional dis- 
turbances of the internally secreting glands. [The probabilities 
seem to me to indicate that endocrinal disorders are the most 
likely etiological factor.] 

Treatment. — Nearly every kind of internal medication has been 
tried in the diffuse sclerodermas; there are no specifics and each case 
will have to be treated according to its own indications. 

Salicylates have seemed to be useful to me; others have advo- 
cated the iodides, arsenic and fibrolysin. Successful results have 
been obtained with thyroid treatment, cautiously and persistently 
administered, but are unfortunately not constant. 

Aside from good hygiene, advantageous use may be made of 
hydrotherapy, the continuous current, electric baths, massage, treat- 
ment with sulphurous or chlorinated waters, various hot springs and 
mud-baths. 

In the partial sclerodermas, negative-pole electrolysis may be 
recommended; the punctures must be applied at considerable 
intervals and only weak currents be used; ionization has likewise 
yielded very encouraging results. Massage, salicylic acid or salol 
ointments are sometimes beneficial. Mercurial plasters have a 
classical reputation. Several of these treatments may, moreover, 
be combined. 



REGIONAL ATROPHIES AND DERMATOSCLEROSES. 

In addition to the macular sclerodermas and atrophies, there 
exist a certain number of clinical types in which the lesions, while 
morphologically analogous, are distinctly regional. 

Whether they be related or not to the affections described above, 
23 



354 CUTANEOUS ATROPHIES, SCLEROSES AND DYSTROPHIES 

the identity of the derniatological lesion leads me to consider them 
in this connection. 

Facial Hemiatrophy. — This affection — also known as tropho- 
neurosis facialis or aplasia laminaris — consists of a very marked thin- 
ning of the skin of one-half of the face, without sclerosis or adhesion. 
The atrophy extends to the corresponding half of the palate, the 
velum and sometimes the tongue. The prominences of the bony 
framework are likewise reduced. The affected side seems to be 
changed as if by old age and situated on a plane behind its normal. 
The skin is white or pigmented; the sensibility is intact, but 
anidrosis and alopecia are present. 

This Aery rare affection begins in youth in the form of patches 
which gradually spread. Some authors compare it with sclero- 
derma. Cases of coincidence of this disease with a scleroderma in 
extensive patches have been reported. 

Kraurosis Vulvae. — The term "kraurosis" (Breisky), the meaning 
of which was rather vague, has been more accurately defined 
especially by the work of Jayle, and must be reserved for a pro- 
gressive sclerotic atrophy of the cutaneo-mucous tissues of the vulva, 
gradually leading to stenosis of the vaginal orifice, disappearance 
of the labia minora, the prepuce and frenum of the clitoris and the 
obliteration of the labia majora. [I have seen the process extent 
to the anal orifice.] The mucosa of the affected regions is always 
smooth, glistening, and dry; its color is white, or red, or mottled. 
Complication with leukoplakia is common and, in this case, cancer 
is not rare. 

The exclusive or principal pathogenic condition of kraurosis 
seems to be the suppression of the ovarian functions through senile 
involution, sclerotic atrophy, or castration; syphilis seems to play 
a part in some cases. 

Kraurosis must not be confused with simple vulvar leukoplakia 
nor with the white coloration of the vulva through lichenization, 
which occurs in prolonged cases of vulvar pruritus. Aside from treat- 
ment with warm irrigations and the high frequency current, exten- 
sive excisions must not be delayed in cases of threatened cancer. 

Dermatoscleroses of the Legs. — In many adults and in old people 
the skin of the legs is the seat of very polymorphous but equivalent 
pathological changes which may terminate either in sclerotic atrophy 
or in elephantiastic pachyderma. 

In the etiology, the patient's sex is of small importance; but 
predisposing conditions are represented by an age between thirty 
and forty-five years, laborious occupations requiring prolonged 
standing, repeated pregnancies, phlebitis, traumatisms, etc. Re- 
cently, the influence of syphilis and tuberculosis has been inves- 
tigated. The essential factors seem to be arteriosclerosis and 



CUTANEOUS DYSTROPHIES 355 

especially varicosities. Both legs are usually involved, although in 
different degrees. 

Varicosities, especially the deep and slightly apparent ones, lead 
to congestion and lowered nutrition; edema and hematic pigmen- 
tations follow; the soil is prepared for complications, varicose 
eczema, phlebitis and ulcers, which further aggravate the nutri- 
tional disturbance by giving rise to thromboses and opening an 
avenue to infections, lymphangitis, etc. 

The resulting dermatosclerosis, which is alone to be discussed in 
this place, may be diffuse or circumscribed. 

In the former case, the diffuse form, the skin is adherent to the 
tibia and the aponeurosis, of a pasteboard-like or woody hardness, 
impossible to raise or fold; its color is earthy or checkered with 
purple or brown, with depressed white spots. Its surface is smooth, 
shining or scaling and cracked; sometimes it is covered by a thick 
layer of dry or oily brownish crusts under which may be found 
pinkish, moist or plainly eczematous surfaces. These changes 
surround the entire circumference of the leg and extend as far up 
as the knee; the foot is usually merely edematous and the nails 
onychogry photic. 

In the circumscribed form, there exist one or several hard, pinkish 
or pigmented patches, level with the skin or slightly depressed, 
deeply adherent, often extending into the hypoderm in thick 
nodular strands. These are sclerotic foci of periphlebitic origin. 
A variety of reticulated sclerosis, of checkered hue, is also met with, 
especially in the neighborhood of the ankles. 

This dermatosclerosis is differentiated from progressive sclero- 
derma by its definite localization; from scleroderma in patches by 
the absence of a distinct boundary and a lilac ring; from the cica- 
trices of ulcers, which often exist at the same time, by the absence 
of a distinct thickened border, which is characteristic of the latter. 

The efficacy of the treatment depends upon the degree and dura- 
tion of the lesions. Complete rest in bed, with elevation of the 
legs, cleanliness and the dressings required by the condition of the 
skin, lead to progressive improvement, which is often considerable 
and may be further augmented by massage and radiotherapy. 
The patient must be instructed to wear roller-bandages or elastic 
stockings. 

CUTANEOUS DYSTROPHIES. 

Xeroderma Pigmentosum. — This dystrophy was first described by 
Kaposi and also bears the names of melanosis lenticularis progressiva 
(Pick), atrophoderma pigmentosum (R. Croker), and epithelioma- 
tosis pigmentosa (E. Besnier). It is familial and of congenital origin, 
although it does not manifest itself until the first years of childhood , 



356 CUTANEOUS ATROPHIES, SCLEROSES AND DYSTROPHIES 

The influence of consanguinity of the parents has been shown by 
statistics (11.8 per cent, of the cases). Sometimes the children of 
one sex are alone affected 

The lesions of xeroderma pigmentosum, resulting from an ab- 
normal sensibility to light-rays, are essentially regional and affect 
the uncovered regions, face, neck, hands, forearms, sometimes the 
legs and the feet, rarely the trunk. 

At the onset, usually in the spring or summer and after a solar 
erythema, the skin is seen to become covered with lenticular pig- 
mentary spots of the appearance and size of freckles or larger. It 
soon becomes abnormally dry and peels in fine lamelhe, and later is 
mottled with telangiectases and atrophic white spots. The latter 




113 



erma pigmentosum. (Author's photograph.) 



may follow upon impetiginous lesions or verrucosities, or originate 
spontaneously. Finally the tissues become atrophied and con- 
tracted, whence ectropion, atresia of the mouth, thinning of the 
nose and ears, etc.; sometimes conjunctivitis and photophobia arc 
noted. 

The mottled appearance resulting from atrophic and red spots, 
stellate telangiectases and pigmentary spots, is characteristic. 

More or less delayed, often about the age of eight or ten years, 
various new-formations appear upon this background (Fig. 113); 
dry verrucous elevations, red and flabby protuberances of sarco- 



CUTANEOUS DYSTROPHIES 357 

matous or angiomatous appearance ; finally, epitheliomas of various 
types, fungoid or ulcerative, which usually result from the malignant 
transformation of the warty growths. These various tumors may 
sometimes heal ; but, as a rule, the epitheliomas become mutilating, 
involve the glands and lead to early death, usually before the age 
of twelve years. A few individuals, however, have lived to the 
age of forty. 

The patholagical anatomy affords scanty information as to the 
nature of the disease. Epidermic hypertrophy and atrophy of the 
derma are demonstrable; the various neoplasms mentioned have 
their ordinary structure, the epitheliomas are sometimes tubular, 
sometimes lobulated. 

The nature of xeroderma consists primarily of a cutaneous mal- 
formation of the type of nevic diseases, characterized by hyper- 
sensibility of the skin to light radiations which leads secondarily 
to a degeneration analogous to the degenerative changes of presenile 
and senile dystrophy, radiodermatitis and arsenic poisoning. 

The prognosis is very grave, but varies with the severity of the 
case and the treatment. 

The treatment consists principally in the avoidance of sunlight; 
the covering of the skin with protective pastes containing quinine 
salts or aesculin; sometimes, it is useful to cover it with masks of 
mercurial or red oxide plaster. 

Special care must be taken to destroy one by one, and very 
promptly, the neoplasms which develop, even the simple verrucosi- 
ties, making use of the curette, the bistoury, the galvanocautery, 
caustic agents, or electrolysis; radium has recently been recom- 
mended. Internal medication is apparently of no use. 

Senile Degeneration. — The degeneration or senile atrophy of the 
skin, which regularly occurs at an advanced age, begins sooner or 
later after the age of forty, according to the mode of life, the 
general health and the heredity of the individual. 

Exposure to inclemencies of the weather plays a certain part, 
the uncovered portions, like the face, the neck and the back of the 
hands and wrists, being the earliest and worst affected; bad general 
and local hygiene, excesses, loss of sleep and diseases of all kinds, 
also act as predisposing factors. 

Senile degeneration manifests itself as changes in the thickness 
and color of the skin, dryness and a diminished plasticity, which 
results in wrinkles. 

Two types may be distinguished and are often associated : 

The most common is simple atrophy, characterized by a parch- 
ment-like thinning, a yellowish, grayish or reddish color and trans- 
parency of the skin, rendering visible the veins, muscles, and 
tendons, etc.; its surface is shining or in a state of ichthyosiform 



358 CUTANEOUS ATROPHIES, SCLEROSES AND DYSTROPHIES 

xeroderma. Pigmentary or achromic spots, telangiectasis and some- 
times purpura senilis arc often present at the same time. Aside 
from the above mentioned regions, the extensor surfaces of the joints 
are the most affected. 

The second type is colloid atrophy, in which the skin is not thinned, 
sometimes on the contrary thickened, but of a straw-yellow or old 
ivory color, an uneven surface like orange-peel, soft and flabby, 
distended and folded. This condition is observed especially on the 
neck and the entire face, except the cartilaginous region of the nose. 

Histology shows as the principal lesion an alteration of the 
elastic fibers. In the atrophic type, they have only become baso- 
philic (elacine of Unna) and the connective tissue is rarefied. In 
the colloid type, they are furthermore swollen and perhaps com- 
bined with the substance of the connective-tissue bundles (collastine 
and collacine). In this case there is found under the epidermis a 
continuous felt-like band, from I to § mm. in width, staining black 
with acid orceine; this is the diffuse elastoma of Dubreuilh (1913). 
Several authors have erroneously confused this relatively common- 
place lesion with pseudoxanthoma elasticum. The epidermis is 
thinned and hyperpigmented. The papilla? are short; the blood- 
vessels are dilated and surrounded by cells. The glands are atrophied. 

Both types of senile degeneration predispose to the senile keratoses 
which may lead to multiple epitheliomatosis. 

The treatment must be prophylactic and consists in correct 
hygiene. Facial massage, which is wrongfully credited with the 
virtue of curing wrinkles, may seem useful for a while, but is 
followed as a rule by an exaggeration of the lesions. 

Presenile Dystrophy. — On the uncovered portions of the skin, 
in persons exposed to all kinds of weather, sailors, automobilists, 
aviators, coachmen, farmers, mountaineers, etc., changes entirely 
analogous to those of xeroderma and even more so to those of senile 
degeneration may be observed after the age of twenty-five or thirty 
years. 

Diffuse atrophy, pigmentations, cyanosis, telangiectasis and 
keratosis are met with; this dystrophy also terminates in multiple 
epitheliomatosis. 

All authors point out the striking resemblance often presented 
by the skin affected with chronic radiodermalitis to that of xero- 
derma and the senile and presenile dystrophies. The analogy extends 
to the identity of the epitheliomatous complications which arc here 
equally frequent. 

Pseudoxanthoma Elasticum. — Under this name I designated, in 
1896, a rare affection, characterized clinically by a yellow hue mixed 
with lilac, with thickening, softness and relaxation of the skin in 
certain regions. It appears in youthful individuals and in adults. 



CUTANEOUS DYSTROPHIES 359 

The changes are preferably localized in the vicinity of the great 
articular folds, groins, axillae, bends of the elbow and even on the 
neck; it has never been observed in the face. Furthermore, around 
the dystrophic surfaces are seen perifollicular spots of the same 
appearance, of slightly prominent, soft, yellowish papules. 

However, the analogy to xanthoma is only apparent. Histologic- 
ally the condition is a degeneration of the elastic network of the deep 
portions of the corium; its fibers swell, proliferate, split and break 
up into fragments. I have given to this special lesion the name of 
elastorrhexis. 

Certain authors, especially impressed by the elastic hyperplasia, 
have interpreted it as an elastoma or hamartoma, regarding this 
degeneration as a sort of widespread tumor. 

At any rate, the nature of the lesions of pseudoxanthoma (elastor- 
rhexis), their seat and distribution, as well as the age at which the 
affection appears, plainly distinguish it from the ordinary senile 
colloid degeneration, or diffuse elastoma. It progresses slowly and 
persists indefinitely. 

Colloid Milium. — Also named miliary colloid degeneration of the 
cutis; this rare dystrophy first described by E. Wagner, then by E. 
Besnier, manifests itself as translucid, soft yellowish elevations, 
disseminated or conglomerated, situated on the face, the neck and 
the upper limbs. This condition should accordingly be studied 
rather with the benign tumors of the skin (XXXI). 



CHAPTER XVIII. 
CUTANEOUS HYPERTROPHIES. 

Under the name of cutaneous hypertrophy or pachi/derma, I 
designate a persistent increase in thickness of the skin as a whole, 
due to an interstitial fibrous hyperplasia. 

Partial thickenings, affecting the epidermis alone, or the papillary 
body, have been discussed elsewhere (Chapter XI and XII). 

Fibrous or adipose hypertrophy of the hypoderm alone, without 
thickening of the derma does not belong to the domain of derma- 
tology. 

Cutaneous hypertrophy is only very rarely generalized, but may 
be very extensive; it is usually regional. The boundaries of the 
change are almost invariably rather indistinct. 

In pachy derma, the skin is thickened to a variable degree and 
changed in its consistence. As a rule, it is firm, unyielding, or 
actually woody; it is not at all or very slightly depressible, and the 
indenting finger leaves no dimple; it is incompletely reducible by 
compression en masse; it adheres to the subjacent tissues and is not 
easily raised in a fold. Sometimes, however, its consistence is softer 
and more elastic. The condition of the surface and the color of the 
affected regions vary greatly in different cases. 

Cutaneous hypertrophy must be distinguished from three related 
processes, which may, moreover, be combined with it in variable 
degrees: 

Inflammatory infiltration is due to deposits of embryonic cells, or 
cells derived from the blood, in the tissues; it behaves like the acute 
inflammations or, when subacute, it is as a rule more or less circum- 
scribed and follows a progressive or a retrogressive course. In both 
cases, however, it sometimes terminates in hypertrophy. 

Edema, the result of a fluid exudate which infiltrates the tissue, 
is depressible, plastic, retains the imprint of the finger and is entirely 
reducible by compression en masse, even in chronic cases. Edemas 
of mechanical or dyscratic origin, such as those of cardiac or Bright's 
disease, etc., never lead to pachyderma. Inflammatory edemas, 
on the contrary, are not infrequently the starting-point of pachy- 
dermas, with which they are connected by imperceptible transitions, 
as illustrated by the often used term of clephantiastic edema. 

Tumors are circumscribed, heterotopic or hyperplastic new- 
growths instead of simple hypertrophies. The question often arises, 



ELEPHANTIASIS 361 

however, in which group a given swelling properly belongs; for 
instance, an elephantiasis limited to an eyelid or a labium majus 
may be mistaken for a myxoma, or a bunch of lymphatic varicosities 
may have the appearance of a lymphangioma, etc. 

Hypertrophic Dermatoses. — The typical form of pachyderma, 
whose clinical features and lesions conform to the definition given 
above, is called Elephantiasis arabum (in contradistinction to 
Elephantiasis grcecorum, which is leprosy), or briefly elephantiasis. 
It will be discussed first in order. 

Another section will comprise a series of affections which I group 
under the heading of non-elephantiastic hypertrophies. These form 
a very heterogeneous group. The differential diagnosis of the 
genuine elephantiasis will be discussed in dealing with them. 

ELEPHANTIASIS. 

Elephantiasis is a regional cutaneous hypertrophy characterized 
by its course and its pathogenesis. 

According to the etiological factors, the following clinical forms 
are distinguished: Elephantiasis nostras; secondary elephantiasis; 
filarial elephantiasis and congenital elephantiasis. 

The symptomatology of elephantiasis in general, irrespective of 
its origin, is as follows: The elephantiastic process begins with 
edema, the inflammatory character of which is sometimes clearly 
evident, sometimes not noticeable. Ultimately, a firm non-plastic 
tumefaction is established, constituting sclerotic or elephantiastic 
edema. In the fully developed stage, pachyderma is present, com- 
bined with a variable degree of hypertrophy of the subjacent 
tissues and associated with all the attributes mentioned above. 
This process is apparently brought about through the association 
of three pathogenic factors: lymphatic congestion, inflammation 
and venous congestion. 

The course of the disease is intermittent; it is indefinitely pro- 
gressive and more or less extensive. 

Symptoms. — The affected regions are swollen, tense and hyper- 
trophied; their normal elevations and depressions are obliterated; 
sometimes, they are crossed by deep grooves. 

The lower limb, for example, which on account of less favorable 
circulatory conditions, is the chief seat of election in elephantiasis 
assumes the appearance of a column or an elephant's leg (Fig. 114). 
The integument is enormously thickened and adherent to the deep 
tissues. Its consistence, which is that of a doughy firmness at the 
thigh, usually becomes harder and more resistant as it approaches 
the malleoli where it is sometimes woody. 

The surface may be smooth and of normal color, or purplish, or 



362 



CUTANEOUS iiYi'Eirnioi'iiiF.s 



brownish; again, it may be covered with laminated scales, or 
cracked hyperkeratoses; in the majority of the cases, it is covered 
by more or less conglomerated verrucosities, of unequal size, rounded 
and of the size of a millet-seed to thai of a cherry-pit; or papilloma- 
tous, acuminate or obtuse and crowded together. These verrucosi- 
ties may l>e pinkish or white, slightly reducible and translucid like 




Fig. 114. — Elephantiasis nostras, consecutive to an ulcer of the leg. 



large vesicles; in this case, they are due to lymphangiectases or 
lymphatic varicosities, which can be pricked with a needle and yield 
a profuse, prolonged flow of lymph (lymphorrhea) ; in other cases, 
they are hard, polygonal through mutual pressure and often covered 
with a hyperkeratotic layer, of dry or oily consistence, of a dirty 
gray or blackish color. Under the crusts, as well as in the grooves, 
a macerated and fetid epidermis is exposed and sometimes ulcers 



ELEPHANTIASIS 



363 



are present having an irregular outline and floor with a sanious 
discharge. 

On the legs, elephantiasis is unilateral or bilateral. When it is 
caused by a local lesion, such as an ulcer of the leg, the pachyderma 
develops below this lesion, consequently on the foot. When the 
causative lesions are situated higher up, the elephantiasis is on the 
contrary often limited by the malleoli, forming an enormous cushion 
which is separated from the foot by one or several deep grooves. 
The foot may retain its normal volume, but is usually swollen and 
verrucous in its dorsal region, chiefly near the toes and above the 
heel. 




Fig. 115. — Elephantiasis of the scrotum, of filarial origin in an Arab. Case and 
photograph of Dr. Raynaud, Algiers. 



The thighs are invaded from below upward, or consecutively to 
elephantiasis of the external genital organs. 

The latter constitute the second seat of election of elephantiasis. 
In men, hypertrophy of the sheath of the penis may transform this 
organ into a pear-shaped mass 20 to 40 cm. in length. When the 
scrotum is the seat of elephantiasis, it may become as large as or 
larger than an adult's head (Fig. 115), engulfing the penis; its surface 
is smooth or verrucose. The name lymph-scrotum is applied to 
elephantiasis of the scrotum with very pronounced lymphatic 
varicosities. 



364 



CUTANEOUS HYPERTROPHIES 



In women, various portions of the vulva, especially the labia 
niajora and minora, or only one of these, assume an enormous size; 
the condition may simulate a myxoma (Fig. 116). I have elsewhere 
mentioned the syndrome of esthiomene, which maybe brought about 
by a variety of vulvar ulcerations accompanied by elephantiastic 
hypertrophy. 




Fig. 116. — Elephantiasis nostras of the vulva. 

In the groins, elephantiasis gives rise to general tumefaction with 
enormous lymphatic dilatations, known as aderto-lymphocele. 




Fig. 1 17. -Elephantiasis of the face; elephantiastic edema of the eyelids, following 
repeated attacks of erysipelas. 



The upper extremities which are rarely attacked separately, are 
transformed into monstrous sausages, constricted at the elbows 
and the wrists. 



ELEPHANTIASIS 365 

In the face, elephantiasis generally appears in the form of per- 
manent bloating, a flabby but non-plastic edema, usually consecu- 
tive to recurrent erysipelas. It may occupy the entire face and 
be accompanied by lymphatic varicosities of the mouth. In other 
cases it predominates in a given region, for example at the ears. 
The eyelids, especially the lower lid, may become the seat of a 
smooth pseudo-myxomatous globular swelling (Fig. 117). On the 
lips, nose and chin, elephantiasis is usually secondary to the lesions 
of lupus or leprosy, or especially sclero-gummous syphilides; the 
resulting facies is called leontiasis. 

It is fairly common, in all kinds of elephantiasis, for several 
territories to be invaded at once or consecutively, for instance a 
lower limb and the genital organs or a leg and an arm, etc. 

At the borders of the elephantiastic regions, the transition into 
the normal condition is always gradual; the intermediate zone is 
edematous and soft. 

The corresponding glands are always altered, usually indurated 
and involved in the general swelling ; they may be impalpable in the 
fibro-edematous swelling. 

Pathological Anatomy.- — The elephantiastic tissues are tough, 
resistant under the knife or merely firm, but always translucid, of 
gelatinous appearance, gorged with plasma which escapes abundantly 
from the cut surface. The cutis, the thickness of which may reach 
2 or 3 cm., the hypoderm two or three times thicker, with the 
muscles and aponeuroses, etc., form a single lardaceous mass which 
extends as far as the bones which also are sometimes hyperplastic. 
The vessels, especially the veins and the lymphatics, are seen 
gaping in cross-sections, producing a riddled or cavernous appear- 
ance. 

The microscope shows in all cases a new formation of young or 
of fibrous connective tissue, without an elastic plexus, sometimes 
purely interstitial, sometimes forming besides an additional layer 
between the corium and the greatly hypertrophied papillae. Between 
the connective-tissue bundles, the connective cells are hyperplastic, 
sometimes of giant size; collections of leukocytes and plasmocytes 
are also met with. The vascular walls are thickened, infiltrated 
with cells, or sclerotic. The muscles and glands are atrophied. The 
adipose tissue often seems to be increased. 

Briefly, the inflammatory character of the lesions and on the 
other hand the venous and lymphatic stasis, are distinctly evident; 
all the supporting tissues are hyperplastic. 

The corresponding glands are sclerotic, as a rule; sometimes they 
are found to be transformed into a fibrous shell, invaded by fatty 
degeneration or into lymphatic cavernous tissue. In secondary 
elephantiasis, they are often degenerated. In an operation upon 



3GG CUTANEOUS HYPERTROPHIES 

tropical elephantiasis of the scrotum, an adult filaria was found 
in the excised tissues. 

I have repeatedly observed remains of phlebitis obliterans in the 
large veins supplying the elephantiastic regions. 

Pathogenesis. — The most plausible explanation of the lesions of 
elephantiasis refers them in the first place to stasis, especially 
lymphatic but also venous, leading to edema; and to a con- 
secutive, or rather concomitant, irritation of the connective tissues. 
( 'ruveilhier particularly stresses the venous lesions, Virchow, the 
glandular obstruction. 

Although experimental elephantiasis cannot be arbitrarily pro- 
duced, it has several times been involuntarily caused in man through 
the extirpation of a group of suppurating or sclerotic glands, or 
through paraffin injections which have obliterated a lymphatic 
plexus. 

Various infections or neoplastic processes may result in the con- 
ditions essential to the development of elephantiasis; local tuber- 
culosis, tertian syphilis and cancer may become complicated by 
secondary elephantiasis. 

The relation of filariasis to the endemic elephantiasis of tropical 
countries is no longer questioned, but superadded infections may be 
suspected of playing a certain part in such cases. 

The relations of elephantiasis nostras to ordinary lymphangitis 
had long been known when Achalme and Sabouraud demonstrated 
the presence of the streptococcus in the elephantiastic tissues in the 
course of acute attacks. Later it was shown that other micro- 
organisms may take its place. 

The infection is exogenic and primary, or it may be secondary, 
for instance to ulcerative lesions, in other cases it seems to be 
endogenic, derived from remote foci, or lurking for a long time, even 
indefinitely, in a state of latent infection in territories which have 
once been invaded. Those who are familiar with the lymphangitic, 
phlebitic and glandular lesions of streptococcus and of erysipelas in 
particular, will not be surprised to see that elephantiasis may result 
therefrom. 

Treatment. — An acute attack should be treated, like all cases of 
lymphangitis, by absolute rest, with elevation of the affected limb 
and moist dressings, or applications of ichthyol, thiol, etc. 

Elephantiasis in the sluggish state must first be cleansed from the 
crusts and coatings by means of baths, fomentations, and oily 
inunctions; ulcers should be disinfected and dressed. Next, always 
assisted by rest in the position most favorable to decongestion of the 
affected part, systematic massage should be employed with com- 
pression by cotton-padded bandages, or preferably elastic bandages, 
proceeding cautiously and closely watching developments. The 



ELEPHANTIASIS 367 

results obtained by these methods are sometimes remarkable, but 
nevertheless as a rule incomplete. Castellani adds to the elastic 
compression, which must be kept up night and day for three to six 
months, daily injections of 2 to 4 cm. of fibrolysin. In case of 
syphilis, specific treatment would of course be indicated. Anti- 
streptococcus serum seems to be of slight efficiency. In hard 
elephantiastic edemas, Denis recommends injections of "du Breuil" 
water. 

When sclerosis predominates and compression is no longer suc- 
cessful, galvanic electricity, advocated by Moncorvo and Silva da 
Araujo, is very valuable for softening the indurated tissues. The 
negative pole is represented by a bath in which the affected part is 
placed, or by moist compresses in which it is wrapped, the posi- 
tive pole being applied to the healthy tissues; strong currents are 
required. Still better results can undoubtedly be accomplished by 
means of ionic medication. Attempts to perform "lymphangio- 
plasty," through subcutaneous filiform drainage, are very variably 
estimated. 

Some cases of elephantiasis, notably of the scrotum and penis in 
hot countries, constitute a disease against which extensive surgical 
ablations are the only efficient measure. In case of filariasis, injec- 
tions of arsenobenzol will cause the filarial to disappear from the 
blood, but they do not seem to act upon the elephantiasis. 

Elephantiasis Nostras. — This is observed in adults of all ages, 
and in both sexes. 

In a considerable number of cases, the portal of entrance of the 
infection, usually streptococcic, is obvious — a scratch, an incised 
corn, or any kind of erosion. The first lymphangitis may be of 
violent, abrupt onset, with edematous and painful progressive 
redness, long red streaks, glandular swelling and associated febrile 
malaise. Sometimes, especially in the face, it appears as a typical 
erysipelas. All the symptoms subside after a few days, but there 
follow repeated, sometimes rhythmical recrudescences, following 
traumatism, fatigue, exposure to cold, or ordinary causes; these 
are often less violent but more protracted than the first attack. 
The tumefaction, which had not entirely subsided before, becomes 
established and gradually increases. 

In other cases, the initial lesion remains unknown. The attacks 
are afebrile and are marked only by heaviness or tenderness of the 
affected region, articular pains, etc. The lymphangitis in this case 
is not apparent, but nevertheless everything points to the occur- 
rence of a lymphatic obstruction. 

Such an obstruction appears evident in a third group where the 
elephantiasis develops as the result of an adenopathy. Tuberculosis 
of a group of glands, cancerous adenopathy, sclerotic adenopathy 



368 



CUTANEOUS HYPERTROPHIES 



following upon syphilis, a suppurating glandular in Ha mm at ion, or 
surgical extirpation of glands, may lead to elephantiasis of the cor- 
responding territories. One of the lower limbs, or the genital organs, 
or both these regions together, will be involved in the case of inguinal 
adenopathy (Fig. 118); the upper limb, as a sequel to cancerous 
axillary adenopathy, which is so common 
in the course of cancer of the breast; the 
face, in the case of submaxillary adenop- 
athy. 

Gradually, without inflammatory attacks, 
the above outlined clinical picture develops; 
lymphatic varicosities, lymphoceles and 
lymphatic fistulas are especially frequent 
and important in this group of cases. 

Secondary Elephantiasis or Elephanti- 
astic Conditions. — This is by far the most 
common form of elephantiasis in our 
climates. In these cases, sclerotic edema, 
then elephantiastic, usually verrucous 
pachyderma develop in connection with a 
local lesion of which they represent a com- 
plication. 

Elephantiastic conditions are observed 
in the course of cutaneous tuberculosis and 
especially lupus of the limbs (elephantiastic 
lupus); in tertiary syphilis, especially as 
the result of recurrent gummous infiltra- 
tion on the limbs or on the genital organs, 
also at the circumference of the mouth and 
nose (syphilitic leontiasis); in leprosy, when 
incurable ulcers are present; in the course 
of leg ulcers, where one may observe the 
formation not only of a callous cushion, 
but also of monstrous deformities (Fig. 
114), above the ulcer or its cicatrix. 

The pathogenesis of these elephantiastic 
conditions is often complicated, so that it 
would not be justifiable to divide them into 
tuberculous, syphilitic, etc., elephantiasis. 
The specific process undoubtedly invades the lymphatics and veins 
of the affected region; but in addition, the corresponding glands 
are degenerated or sclerotic; finally, secondary infection of the 
ulcerations by the streptococcus or other microbes, whether revealed 
or not through attacks of lymphangitis, is extremely probable and 
can be bacteriologically demonstrated in some of the cases. 




Fig. 118. — Elephantiasis 
nostras of the lower limb 
with lymphatic varicosities 
of the scrotum and at three 
points on the thigh. The 
lesions in this young man 
were consecutive to tuber- 
cular adenopathy of the 
inguinal glands. These de 
Guillemin, Paris, 1900. 



ELEPHANTIASIS 369 

It is useful to know that after syphilitic chancrous lymphangitis, 
it is not uncommon to observe a sclerotic edema of the prepuce and 
sheath, or of a labium majus, undoubtedly due to a specific lymphan- 
gitis through the spirochete; this lesion may subside more or less 
gradually under the influence of antisyphilitic treatment. 

Elephantiasis Filariosa. — In many tropical countries, cases of 
elephantiasis are extremely common; some are probably referable 
to the various pathogenic factors mentioned above, but in addition 
there occurs an endemic helminthiasis, known as filariasis, which 
may give rise to lymphangitis, orchitis, lymphangiectasis, lymph 
scrotum, filarial abscesses, chyluria, chylous hydrocele and also 
frequently to elephantiasis. 




♦ o° o° 
oo 



J 6 



oo 



Fig. 119. — Filaria sanguinis hominis, surrounded by red corpuscles. Drawn from 
a fresh specimen prepared by Dr. Jolly. X 300. 

It is caused by the filaria Bancrofti and its embryos, the so-called 
microfilaria. This worm is a nematode, the adult female, discovered 
by Bancroft in 1876, measuring 8 to 10 cm. in length, while the male 
is considerably smaller; they lodge, a few in number, in the large 
lymph trunks or glands, where the female hatches innumerable 
embryos which resemble small active eels, about 300^ long, from 
7 to 9^ wide, enclosed in a glassy sheath. These microfilarias were 
seen by Demarquay (1863) in a chylocele and by Lewis (1877) in 
the circulating blood (Filaria sanguinis hominis) where they are 
found only during the night and should be looked for about mid- 
night in doubtful cases; in the daytime they withdraw into the 
pulmonary vessels, according to the observation of P. Manson. 

The disease is transmitted through mosquitoes, which in stinging 
the patients absorb the embryos; these undergo a metamorphosis 
in the thoracic muscles of the insect and are then inoculated into 
other human subjects, where they reach maturity. 

The etiological role of these parasites in elephantiasis seems to 
rest on the very frequent association in the same countries and 
24 



370 CUTANEOUS HYPERTROPHIES 

in the same patients, of monstrous pachydermas and other symp- 
toms of filariasis. It must be admitted, however, that numerous 
filaria-bearers have no elephantiasis and that on the other hand 
in many elephantiasis cases in hot countries, the embryos cannot be 
demonstrated in the blood. 

It is accordingly possible that the obstruction of the large lym- 
1 >hatic trunks by the adult filaria, or of a large number of lymph vessels 
by ova which have not reached maturity (P. Manson), or the inva- 
sion of the embryos into the connective-tissue interstices of the 
affected parts, are sufficient causes of the elephantiasis; it is also 
possible that the filariasis constitutes merely a predisposing cause of 
ordinary elephantiasis. 

At any rate, filarial elephantiasis is observed in infected countries, 
in all races, in both sexes, at all ages, but especially in adults. In 
95 per cent, of the cases it occupies the lower limbs, one or both; 
very frequently also the external genital organs. It proceeds by 
lymphangitic or erysipeloid attacks, often with fever (filarial fever), 
with general symptoms and adenites, precisely as in elephantiasis 
nostras. In one case, Le Dantec was able to isolate and cultivate 
a "dermatococcus." 

The symptomatic shades which distinguish tropical elephantiasis 
from the domestic form consist of its often excessive development 
and its frequent association with enormous lymphatic varicosities 
or other filarial manifestations. 

Congenital Elephantiasis. — Under this term are united a long 
array of heterogeneous cases in which an enormous hypertrophy of 
a portion of the body was demonstrated at birth or shortly after- 
ward. There is reason to suspect the following conditions, in differ- 
ent cases: 

Giant lipomatosis; diffuse angiomas and lymphangiomas; lym- 
phatic edemas due to tumors or malformations; and finally, neuro- 
fibromas or diffuse fibromatosis. 

According to Moncorvo, who has made a special study of this 
subject, there exists a genuine fetal elephantiasis, due to intra- 
uterine lymphangitis, the pathogenic agent having penetrated by 
the placental- route. Filaria have never been found in the affected 
children. 

The localization is arbitrary; the hypertrophy affects a limb or 
part of a limb, the eyelids, the tongue, etc. 

Congenital macroglossia, for instance, which is one of the most 
peculiar forms, has been referred to a variety of conditions in differ- 
ent cases, fibrinous or muscular hypertrophy, cavernous angioma 
and especially diffuse lymphangioma. 

The subject is complex and as yet imperfectly understood. 



NON-ELEPHANTIASTIC HYPERTROPHIES 371 



NON-ELEPHANTIASTIC HYPERTROPHIES. 

Not all regional or diffuse hypertrophies should be described as 
elephantiasis. As has just been seen, the diagnosis may present 
serious difficulties in the newborn; this is not generally the case in 
adults, except in rare cases. 

By means of careful and systematic palpation, it may be recog- 
nized that there exists no true pachyderma in edema, in obesity, in 
the case of lipomas even when regional and symmetrical, in adeno- 
lipomatosis, in adiposis dolorosa of Dercum, in acromegaly, etc., 
which accordingly do not belong to the scope of this book. 

More closely related to elephantiasis, although they remain 
distinct by their clinical and anatomical features and by their 
pathogenesis, are the following diseased conditions: 

Nemo-arthritic Pseudo-elephantiasis. — The observations to which 
this name, due to Mathieu, is applied, as well as that of trophedema 
of Meige (1898) are difficult to interpret. 

Extensive regional edemas, which become chronic and fibrous, 
occur in the absence of a demonstrable cause; in other cases, hard, 
non-depressible swellings are present from the start. The seat of 
predilection of this affection is on the lower limbs, only one of which 
may be involved, or both may be symmetrically swollen and 
enlarged; the genitals escape, as well as the foot, except sometimes 
its dorsal region. The trophedema may likewise affect the upper 
limbs and even the face. 

At first sight the appearance is that of elephantiasis; but the 
skin always remains smooth, of normal color, without verrucosities 
or lymphatic varices; but it is adherent, and cannot be folded or 
indented. 

The onset is often marked by severe neuralgic pains, or by 
spasms, without inflammatory symptoms; exaggerated tendon 
reflexes were noted by me in two cases. All evidences of a disease 
of the nervous system is absent as a rule. 

The affection progresses or remains stationary, always lasting 
many years without other disturbance than an impairment of 
mobility; it may improve under the influence of thyroid treatment, 
massage and compression, or sometimes actually disappear. 

The pathological lesions are not well understood. It is not 
known if this disease is comparable to myxedema, constituting an 
incomplete or abortive form, or to the diffuse hypertrophies which 
sometimes accompany infantile paralysis or paraplegia. It seems 
to be related to the following type: 

Neuro-arthritic Pseudolipoma. — Potain, Bucquoy, Mathieu and 
others, have described under this name tumefactions having a 
supraclavicular and symmetrical seat of election, supposed to be 



372 CUTANEOUS HYPERTROPHIES 

angioneurotic edemas, plastic at the onset, then fibrolipomatous, 
indistinctly outlined. Their true character has not yet been 
established. 

Dermatolyses. — These malformations are always partial, usually 
congenital, but sometimes developing a considerable time after 
birth. They consist of thickening and well marked loosening of the 
skin in certain regions of the body. 

Alibert recognized palpebral, facial, cervical, ventral and genital 
dermatolyses; still others may be observed, notably on the lower 
limbs. The denominations pachydermatocele (Mott) and chaJazo- 
derma (Bazin) are less commonly employed. 

The relaxed skin forms large, thick and flabby folds which are 
dragged by their own weight so as to cover the subjacent parts, 
sometimes hanging down like an apron. 

The majority of the cases of this group are probably referable to 
v. Recklinghausen's disease, in which the "major tumor" is repre- 
sented by the pachydermoceie. Swollen and nodular nerve-strands 
have been demonstrated therein (plexiform neuroma) and in several 
instances the patients were at the same time the bearers of smaller 
mollusca. 

Ordinary relaxation of the skin due to pregnancy, senility, etc., 
is not true dermatolysis. 

Cutis Hyperelastica, or Cutis Laxa, is a different malformation in 
which the skin of certain regions, without being distended or loos- 
ened, is of a doughy consistence, extraordinarily distensible, and 
suddenly resumes its place when liberated after stretching. Some 
of the "rubber men," exhibited in side-shows, can pull the skin of 
the neck up to the forehead, etc. 

Myxedema. — Myxedema, or pachydermia cachexia, is a general 
dystrophy dependent upon thyroid insufficiency. 

It is observed under a great variety of conditions, especially in 
women (Gull, Ord), or as a sequel of total extirpation of a goitre 
{cachexia strumipriva, J. Reverdin of Geneva and Kocher of Bern), 
also in children (myxodematous idiocy of Bourneville); the latter, 
which in combination with goitre constitutes cretinism, is known to 
be endemic in certain mountainous regions. 

The principal symptoms are of a general kind: mental sluggish- 
ness, slowness of movements and of speech, anorexia, a retarded 
pulse, a lowered temperature and a sensation of chilliness; in 
children, idiocy and an enormous retardation in growth. Instead 
of dwelling upon these, I shall pass on to the external symptoms: 

The integument is swollen, waxy white, dry, scaly, indurated and 
docs not retain the imprint of the finger. The hairs fall out, the 
sebaceous and sweat secretions are suppressed. 

The appearance is characteristic: the bloated "full-moon" face, 



NON-ELEPHANTIASTIC HYPERTROPHIES 373 

the hanging cheeks, the large nose, the swollen and open lips, con- 
vey an impression of imbecility. The buccal mucosa may be swollen 
and waxy. The neck is enlarged and the thyroid gland is not demon- 
strable on palpation. An analogous condition exists on the trunk 
and especially on the extremities, which may present a pseudo- 
elephantiastic appearance. 

The hypothyroidism of the menopause, which is very common, 
gives rise to a greatly attenuated picture of myxedema. 

The anatomical lesions, aside from atrophy, degeneration or 
sclerosis of the thyroid gland, in the integument consist of fibrous 
proliferation, with hypertrophy of the adipose layer. 

I do not believe that " an infiltration of the tissues by a substance 
analogous to mucin" has been observed since Ord. But the follow- 
ing have been demonstrated: Collections of inflammatory cells 
(Virchow), which I was enabled to find also in experimental myxe- 
dema in animals; rarefaction with degeneration of the connective- 
tissue bundles; and a degeneration of the elastic fibers as in senile 
change. 

The treatment with thyroid substance is imperative and yields 
remarkable results, but must be kept up indefinitely. Thyroid 
grafting has recently been tried. 

Rhinoscleroma. — This is a progressive hypertrophic affection, 
described by Hebra and Kaposi, restricted to the region of the nose 
and upper lip; it is endemic in certain countries, such as Galicia, 
Hungary, southwestern Russia, etc., and is of microbic origin. [It 
is rare in America and almost always of exotic origin.] 

The lesions usually begin on the septum of the nasal fossse, or at 
the columella and the upper lip in the form of solid elevations, with 
a smooth and tense epidermis, of a red, pink, or pale color, which 
develop into a tumor of cartilaginous hardness resembling a keloid. 

The disease affects both nasal fossa?, which become obstructed; 
the velum of the palate, causing retraction of the uvula; the 
pharynx and larynx, resulting in stenosis; and even the trachea. 

The course is very slow and may lead after twenty years or more 
to death from pulmonary complications. The disease attacks 
youthful or adult individuals, especially of the indigent classes. 

An encapsulated bacillus, the Frisch bacillus, closely related to, 
if not identical with the pneumobacillus of Friedlander, is held to 
be responsible and, it is claimed, has been found in pure culture in 
the glands, which according to Rona are frequently swollen. 

The lesions consist of a sclerogenic cellular infiltration, containing 
large hyaline cells, the origin of which is referred by some to a 
cellular degeneration and by others to a degeneration of the bacilli 
themselves. 

The surgical treatment is usually followed by recurrence; caustic 



:!74 



CUTANEOUS HYPERTROPHIES 



topical applications and interstitial injections arc unreliable pro- 
cedures. Radiotherapy is indicated and has furnished encouraging 
results. 1 1 have definitely cured one ease by means of ./'-ray. 
Autogenous vaccines should be tried in eases not amenable to 
radiotherapy.] 

Rhinophyma and Hypertrophic Acne. The nose is sometimes the 
seat of a psendo-elephantiastie hypertrophy, giving rise to special 
clinical conditions in this region. 

Although without actual gravity and hardly even inconvenient, 
it is readily understood that deformities of this kind are extremely 
distressing to the patients. 



§ 






: 




^P*T 


% 






''■''■ "&)wilBP^ 




■^'''^^k 


^ 


•*-£m$t- : §4jj^^^^ 




-Ifj^^^ 



Fie;. 120. — Acne hypertrophica of the nose. 



These hypertrophies of the nose, more common in men than in 
women, do not occur until about the fiftieth year and affect only 
very kerotic individuals, who have suffered from acne when young; 
often they are complications of so-called " copper-nose." The course 
is progressive and very slow. 

Two forms can be distinguished and are sometimes associated: 
In the glandular variety — or hypertrophic acne of Vidal and 
Leloir — the skin is thickened, but of a normal color; the sebaceous 
pores are dilated and funnel-shaped; the point of a probe may be 



NON-ELEPHANTIASTIC HYPERTROPHIES 375 

introduced and a large amount of a sebaceous, vermicular and fetid 
material squeezed out. 

In the fibrous angiectatic variety — or rhinophyma — the cutaneous 
surface is of a purplish red color, lumpy, furrowed by large-sized 
varicose venules, riddled with sebaceous orifices and often dotted 
with pustules. 

In both forms, the nose is either uniformly increased in size, 
or covered with globular protuberances (Fig. 120) or even with 
pedunculated tumors attached to the lobule or the nostrils, some- 
times reaching or exceeding the size of an egg and hanging down 
to the chin. Their consistence is flabby, uneven, gelatinous. The 
cheeks are sometimes invaded by an analogous proliferation. The 
boundaries of these changes are not well marked. 

The lesions of hypertrophic acne consist of an enormous hyper- 
trophy of the sebaceous glands, with an ampullary dilatation of 
their excretory duct. In rhinophyma, on the contrary, hyperplasia 
of the connective tissue and of the vascular and lymphatic plexus 
predominate. Disseminated foci of cellular infiltration are regularly 
present. Complication with epithelioma has been repeatedly noted. 

The treatment demanded on account of the disfiguring character 
of these affections may consist at the onset of ichthyol applications 
and warm astringent lotions, or strong sulphur lotions, which in 
combination with massage and expression of the sebaceous material, 
may improve the condition of the affected parts. 

It is preferable to interfere actively, without loss of time, by 
means of the galvanocautery, by scarifications, or electrolysis. 

In the presence of a considerable hypertrophy, the operation 
known under the name of decortication, performed with the thermo- 
cautery or the bistoury, yields excellent results; grafts are unneces- 
sary, for the remnants of the divided glands become centers of 
epidermic renewal ; it is essential not to excise too deeply. Recur- 
rences have not been recorded. 



CHAPTER XIX. 
FOLLICULOSES. 

The forms of dermatological lesions which still remain to be 
studied in the first portion of this book have the peculiar feature of 
being characterized, not by the nature of the pathological process, 
but by its localization. 

As folliculoses I designate those pathological processes which 
affect exclusively, or with evident predilection, the pilo-sebaceous 
follicles. 

The syndromes to which they give rise assume a certain appear- 
ance of kinship by virtue of this localization. It is always relatively 
easy, even for a beginner, to determine whether a cutaneous affec- 
tion is follicular or not ; it is far less simple, when dealing with a 
follieulosis, to distinguish its pathological character. This con- 
sideration in my opinion fully justifies the arrangement adopted 
in the following: 

Pilo-sebaceous Follicles. — The pilo-sebaceous follicle is an invagi- 
nation of the epidermis; its floor, raised as a papilla, gives insertion 
to the hair, which is secreted by this papilla; a lateral diverticulum, 
the sebaceous gland, secretes a fatty material, the sebum. 

This follicle, of epithelial structure, projects into the derma, its 
extremity sometimes reaching the hypoderm. It is encased in a 
fibrous follicular sac, into which a muscle with smooth fibers, the 
erector pill, is usually inserted. 

Two details in the structure of the follicle are of special interest 
for the dermatologist. 

The first concerns the difference in its constitution above and 
below the opening of the sebaceous gland. Whereas in the deep 
portion the invaginated epidermis undergoes various modifications 
which transform it into the epithelial sheaths of the hair, it pre- 
serves in the external, less extensive portion, exactly the same char- 
acteristics as on the surface of the skin. This superficial portion, 
the follicular collar, also known as the ostium of the follicle, the pore, 
or on account of its usual form, the follicular funnel, participates 
therefore in the pathology of the surface epithelium. 

Moreover, the follicular pore is especially exposed to repeated 
traumatism, through rubbing and scratching, because the hair 
which traverses it acts as the arm of a lever. 

Finally, it represents an ever-ready receptacle for dust, irritative 



ACUTE SUPPURATIVE FOLLICULI TIDES 377 

matter of occupational, pathological or therapeutic origin and 
notably for microorganisms, pathogenic or saprophytic, to which 
it offers shelter. It has very properly been said that the follicular 
funnel is the flaw in the epidermic armor. 

Another noteworthy anatomical fact is that the pilo-sebaceous 
follicle is surrounded by a network particularly rich in bloodvessels 
and nerves; with the result that the phenomena of reaction are 
easily elicited and well-marked. 

The pilo-sebaceous follicles are distributed, in variable numbers 
and dimensions in different regions, over the entire integument, 
with the sole exception of the palmar, plantar and ungual regions 
and the semimucosse. It is therefore an incorrect expression to 
speak of areas provided with fine downy hairs as glabrous or smooth, 
in contradistinction to hairy regions supplied with coarse hairs. 

Folliculoses. — The affections of the follicles, which I group 
under this heading, are very numerous and variegated. Some con- 
cern the localization of a skin disease which occurs elsewhere, while 
others are pathological conditions peculiar to the follicles. 

In the former case, the follicular localization may be accidental, 
as it were, without lending a special feature to the dermatosis; 
this is the case, for instance, in follicular purpura, in psoriasis, in 
soft chancre, etc. It seems to me superfluous to dwell upon these 
possible peculiarities. 

In other cases, the follicular localization of the dermatosis is elective 
and visibly modifies the clinical picture; the affections of this kind 
(for example: follicular pyodermatitides, follicular syphilides, etc.), 
must necessarily figure in this chapter. 

However, the preceding data do not furnish a sufficient basis of 
classification. The mode of grouping the folliculosis which seems to 
me most in conformity with clinical facts, distinguishes between : 

1. Acute suppurative folliculitides. 

2. Follicular complications of kerosis, namely seborrhea and the 
various acnes which result from the same. 

3. Depilating folliculoses. 

4. Subacute folliculoses , among which belong the follicular locali- 
zations of eczematides, syphilides and tuberculides. 

5. Pityriasis rubra pilaris, which one is inclined at present to 
connect with the preceding group. 

6. Follicular keratoses. 

ACUTE SUPPURATIVE POLLICULITIDES. 

These are subdivided into two groups: those which are purely 
pyococcic, namely due to the ordinary microbes of suppuration; 
and those which are trichophytic. 



378 FOLLWULOSES 

They manifest themselves in the form of pustules pierced by a 
hair through their center, more or less superficial or deep, of 
variable size and surrounded by a congestive halo. 

It has been shown above that Bockhardt's impetigo or staphylo- 
coccic impetigo, tends to assume the form of superficial and intra- 
epidermic osteofollicular pustules; it is unnecessary to repeat its 
description. 

Not uncommonly the superficial suppuration is accompanied or 
complicated by the formation of a minute abscess, situated more 
deeply along the follicle and due to the penetration of the pyogenic 
microbe (Plate II): this condition is notably present in the case of 
folliculitides of the regions with coarse hairs, known under the old 
name of .sycosis (from gvkov = ?l fig.). There are two varieties of 
sycosis: one simple or pyococcic, the other trichophy tic ; the latter 
will be described together with the trichophytic folliculitides. 

Furuncle and carbuncle are acute staphylococcic folliculitides, deep 
from the start, with extensive inflammation, terminating in partial 
necrosis and suppuration. The primary follicular localization, some- 
times very apparent, is less evident in other cases. The reader is 
referred for their description to the chapter on the pyodermati- 
tides. 

Acnes are often pustules, but they represent the inflammation of 
a preliminarily altered follicle and will be discussed in a subsequent 
section . 

Sycosis Simplex. — The acute suppurative staphylococcic follic- 
ulitis of hairy regions, more particularly the beard, give rise to a 
symptom-complex, commonly designated under the name of sycosis 
simplex, vulgaris, or non-parasitic, in contradistinction to tricho- 
phytic sycosis. 

Aside from the moustache and the beard, simple sycosis is met 
with at the pubis and in the axilla? in both sexes and on the hairy 
seal]) in children. 

The peripilar pustules, deep from the start or becoming so later, 
are scattered irregularly or they may be agminated. Sometimes they 
begin as follicular papules or as tuberous elevations or as more or 
less deep and extensive soft infiltrations, causing a sensation of 
tension, heat or shooting pains and suppurating only secondarily; 
often the suppuration is primary and early. The affected regions 
become covered with yellowish or brownish crusts, under which 
the skin is reddened, eroded and thickened; pressure upon them 
causes pus to escape from the enlarged follicular orifices. 

A long while before falling out spontaneously the hairs can be 
pulled out easily and painlessly with forceps or with the fingers; 
they come out with their root surrounded by a gelatinous, trans- 
lucid or opalescent sheath, which is their epithelial sheath infil- 



ACUTE SUPPURATIVE FOLLICV LI TIDES 379 

trated with pus. This sign, which is typical of an involvement of 
the deep portion of the follicle, is absent in osteofollicular impetigo ; 
it suggests that the papilla may be destroyed by the suppuration, 
with the result of permanent alopecia, although this is usually not 
the case. 

Simple sycosis, following upon impetigo, furuncle, panaris, coryza 
or an infection by means of the razor, is spread from one place to 
another and carried to a distance by means of the fingers or toilet 
articles [especially towels]. The deep, intradermic seat of the 
affection, moreover, renders it rather inaccessible to therapeutic 
agents, which explains its obstinate, frequently chronic character 
and its tendency to recurrence. Cases of sycosis of the beard of 
many months' or even years' standing are met with. 

The topography of the lesions permits a separation into several 
clinical types: 

Sycosis of the beard (mentagra of Alibert), usually symmetrical, 
occupies the lower portion of the cheeks, whence it spreads upward 
toward the temples and downward to the subhyoid region, some- 
times reaching the chin. 

Sycosis of the mustache, often situated laterally under one nostril 
before becoming bilateral, is practically always connected with a 
lesion or infection of the corresponding nasal fossa. This mani- 
fests itself by chronic coryza, a habitual mucous or mucopurulent 
nasal discharge and ordinarily gives rise at the same time to follic- 
ulitis of the nasal fossae and ciliary blepharitis or phlyctenular 
conjunctivitis through an ascending infection. It is noteworthy 
that trichophytic sycosis, on the contrary, is extremely rare in the 
region below the nostrils. 

The beard and moustache may be invaded, as a whole, in stru- 
mous or exhausted individuals, convalescents from serious diseases 
or even in apparently healthy men in whom all pus infections find 
an especially favorable soil and tend to last indefinitely in conse- 
quence of an unexplained predisposition. 

In the pubic or axillary region the suppurative folliculitides 
develop especially under cover of uncleanliness and neglect and 
sometimes after scabies. Often, as also in the case of the beard, 
they become superimposed on a seborrheic or artificial eczema. 

The condition sometimes described as eczema pilaris is merely 
an eczema of the hairy regions complicated by a peripilar impeti- 
ginization or by staphylococcic folliculitis. 

On the hairy scalp the folliculitides are observed chiefly in school- 
children. Pediculosis and various traumatisms are common caus- 
ative factors. There may be a rapid and profuse outbreak of sup-- 
purative folliculitis over a part of the scalp or over the entire scalp, 
as the sequel of removal of hairs with the forceps, painting with 



380 FOLLICULOSES 

iodin tincture, application of salves, etc., in the course of treatment, 
for instance, of an attack of tinea. 

The treatment of sycosis vulgaris is likely to be tedious. In the 
first place the diagnosis must have been positively confirmed by 
the microscopic examination of the hairs, showing the absence of 
the trichophyton. 

The rule is to stop the use of the razor, to cut the hairs short with 
scissors, to clean the crusted surfaces with sprays or moist dres- 
sings, to pull out the hairs which are easily detached, to empty the 
pustules and pack them several times daily with absorbent cotton 
soaked in "eau d'Alibour" or in resorcinated or camphorated 
alcohol. 

At the onset, starch poultices are better tolerated than salves or 
pastes containing calomel, yellow oxide, ichthyol, sulphur, salicylic 
acid or resorcin, etc., which may be indicated later on. 

Total epilation is sometimes indispensable, notably when the 
suppuration has reached the depth of the follicle. Preliminary 
radiotherapy greatly facilitates this and by itself alone often acts 
very favorably, even in weak doses. 

In obstinate cases, vaccinotherapy is often advantageously 
employed, either with stock staphylococci or with an autogenous 
vaccine. Good results are sometimes obtained through the appli- 
cation of zinc pastes with oil of cade and sulphur or with ichthyol 
(5 per cent.) containing resorcin (3 to 5 per cent.). 

In the terminal stage, mercurial plasters, sometimes scarifications 
and the x-rays are effective in the obliteration of the indurations. 
Correction of hygienic conditions and general tonic treatment must 
not be neglected; beer-yeast, ferments, arsenic and sulphur water 
may be of use. 

It is needless to say that from the start everything must be done 
to extinguish the original foci of the pyococcic infection and especi- 
ally to cure the chronic coryza in cases of sycosis of the moustache. 

Trichophytic Folliculitides. — The trichophytons which cause sup- 
purative follicular inflammations are ectothrix trichophytons, that 
is, they vegetate in the sheath of the hairs and not or very slightly 
in their interior. Adults are rather more susceptible than children. 
The parasites are directly or indirectly of animal origin. 

Several clinical types of these trichophytic folliculitides may be 
described: 

Sycosis trichophytica barbce is due, in the majority of cases, to the 
trichophyton of horses (trichophyton gypseum); it grows in white 
cultures and is in itself highly pyogenic. It gives rise to peripilar 
pustules, with a fairly intense inflammatory zone and a rapidly 
swelling base; they become agglomerated in red and raised, tuber- 
ous, firm or even indurated patches or masses from which pus 



ACUTE SUPPURATIVE FOLLICU LIT IDES 



381 



escapes through numerous orifices on pressure; sometimes purulent 
sloughs occur. These patches gradually extend peripherally and 
new regions at a distance are attacked. The hairs in the middle 
of the patch easily come out with the forceps and are denuded and 
dead; it is necessary to look at the margins for hairs still provided 
with their root-sheath, where it is easier to find the parasitic spore- 
bearing mycelium under the microscope. 

The lesions are preferably situated in the lower portion of the 
cheeks or the chin, sometimes at the temples or in the hyoid regions 
(Fig. 121) ; they are often asymmetrical; in one case I found them on 
the moustache, an absolutely exceptional location. 




Fig. 121. — Tri exophytic folliculitis of the beard; parasitic sycosis due to tricho- 
phyton ectothrix. After a cast in the Museum of the St. Louis Hospital, Paris. 



Trichophytic sycosis is observed especially in coachmen, grooms, 
knackers, veterinaries and horseshoers. 

Trichophytosis of the beard may assume other aspects; that of 
drier, less suppurative papules or tuberosities; that of red circles 
or arcs, with white scales and dry epidermic plugs, from which a 
broken hair emerges, suggestive of keratosis pilaris, etc. This is 
undoubtedly due to a difference of the trichophytic species; as a 
matter of fact, a bird trichophyton with rose-colored cultures has 



382 FOLLICULOSES 

been demonstrated, a yellow species, the acuminatum, the viola- 
ceum and so forth. 

Kerion Celsi is the name applied to patches of trichophytosis 
occupying the hairy scalp of children or adults and similar to those 
described above in the beard; they are likewise generally due to 
the trichophyton gypseum. 

The condition, as a rule, consists of one or several nummular or 
larger, distinctly elevated, rounded disks, with sharply outlined 
borders of a bright red color; the hairs have fallen or are easily 
detached; there is a scattering of small white pustules which can 
be emptied by pressure. 

Folliculitis Agminata, or Leloir's folliculite conglomeree en placards, 
is the same affection as kerion, but occupies the smooth parts. 
It is observed at all ages, on the wrists, the forearms and the neck. 
The red patch, comparable with a macaroon, is covered with a 
crust or with thick pus; after it has been cleansed it appears inter- 
spersed with dilated follicular orifices which riddle it like a sieve. 
There may be several patches of different ages. Their growth is 
rapid and takes place in a few days. 

The spores and fragments of the mycelium are often difficult to 
demonstrate in the pus, so that the nature of this affection was not 
recognized by Leloir. Like kerion, it sometimes lasts for weeks 
and months, but it may disappear spontaneously. 

The suppurative trichophytic folliculitides leave, as a rule, more 
or less alopecic cicatrices. 

The diagnosis can sometimes be based on the clinical charac- 
ters alone, but should always be confirmed by microscopic exami- 
nation and if possible by culture. The pyococcic folliculitides, 
even when agminated, do not form as distinctly circumscribed 
round patches and are more apt to be disseminated. Furuncle 
and carbuncle have a more pronounced and extensive inflammatory 
edema, are more deeply infiltrated and much more painful. 

The classic treatment of the trichophytic folliculitides, no matter 
where the lesions are situated, consists of the careful epilation of 
the patch and of a peripheral zone of about 1 cm. in width; as 
the hairs are not brittle, radiotherapy may be replaced by avulsion 
with the forceps, followed by the application of emollient or anti- 
septic dressings. It is sometimes necessary to open the deeper fol- 
licular abscesses with the thermocautery. Finally, the affected 
surfaces are freely painted with tincture of iodin every other day, 
or they may be dressed with iodin in vaseline. 

However, all dermatologists have noted that very freely suppurat- 
ing trichophytoses heal spontaneously, as it were; thorough epila- 
tion, cleansing and moist dressings or starch poultices are sufficient. 
This fact is explained either by an immunization or more probably 



SEBORRHEA 383 

by the expulsion of the parasites through the suppurative reaction 
induced by them. 

The precautionary measures necessitated by the contagiosity of 
this affection must, of course, be insisted upon. 

SEBORRHEA. 

The word seborrhea, which means a flow of sebum, was introduced 
in 1840 by Fuchs to designate the condition named acne sebacea, 
by Biett; sebaceous flux, by Rayer and steatorrhea by E. Wilson. 

I have stated above that, in my opinion, seborrhea is one of the 
principal manifestations of a more general diseased condition which 
I have named kerosis. 

The meaning of the term seborrhea has been unreasonably 
extended by authors to the point of applying it to all the other 
manifestations of kerosis, and even, by Hebra, to pityriasis simplex, 
thereby leading to the enormous confusion which still prevails as 
illustrated by the commonly used but highly improper terms of 
seborrhea sicca (for pityriasis simplex), seborrheic eczema (for eczema- 
tide) and so forth. 

Seborrhea is an exaggerated sebaceous secretion. A distinction 
can be made between fatty seborrhea and oily or fluid seborrhea; 
but there are numerous intermediate conditions. 

Fatty seborrhea [seborrhoea steatosa] is characterized by the dila- 
tation of the pore and the "collar" of the follicles, especially those 
with which the larger sebaceous glands are connected, with accu- 
mulation in the osteo-follicular canal of a substance composed of 
horny cells, fat and microbes, namely the sebum. 

Sometimes the horny cells predominate and are concentrically 
arranged, forming the seborrheic utriculus or seborrheic cocoon of 
Sabouraud; a somewhat greater amount of hyperkeratosis results, 
in the comedo of acne. 

In other cases, the fat forms with the horny cells a pasty whitish 
substance, of a butyric acid odor, which can be expressed by squeez- 
ing between two fingernails, under the aspect of a worm or vermi- 
celli; this is the seborrheic filament. 

In order to make sure that the condition is really one of seborrhea, 
instead of a dry follicular keratosis, for example, it is therefore 
necessary to demonstrate that the fatty material under considera- 
tion can actually be pressed out from the dilated follicular orifices. 
This may be done either by compressing the skin between the nails, 
as mentioned above, or by scraping it forcibly with a glass slide or 
a blunt scalpel. The substance thus obtained must be fatty; 
the cocoons or filaments are easily crushed. Under the micro- 
scope are seen fat drops and horny cells or debris of horny cells; 



384 FOLLICU LOSES 

moreover, on staining the specimen with an aniline dye, preferably 
with thionin, an enormous number of microbes become visible. 

( Jredit is due to Sabouraud for having shown that these microbes, 
myriads of which exist in the product of fatty seborrhea, belong to 
a single species the microbadllus of seborrhea. This is very small, 
barrel- or rod-shaped, often curved, and not easily grown in cul- 
tures. Halle and Civatte have demonstrated in my laboratory 
that it grows much more readily and abundantly in anaerobic 
cultures. This bacillus was seen by Unna and Hodara, who inter- 
preted it as the microbe of acne. 

According to Sabouraud, its extreme abundance in pure cultures 
indicates its pathogenic nature, so that seborrhea should be inter- 
preted as a parasitic disease. This theory is not acceptable, and 
it is more likely that this very widespread microbacillus becomes 
implanted whenever it can live and that its growth is secondary 
to the seborrhea. 

Seborrhea oleosa [orfluxus sebctceus] manifests itself, in its milder 
degrees, by a greasy and shining state of the skin, which leaves fat 
spots on paper; in the advanced degrees, actual drops of oil are 
seen to dot the integument. It almost invariably coexists with 
fatty seborrhea. It is very difficult to decide if the fluid fat is 
really derived from the sebaceous glands instead of from the 
sweat glands; namely, if the condition is not one of hyperidrosis 
oleosa. 

The usual distribution of fatty seborrhea is less extensive than 
that attributed to it by those writers who confuse it with kerosis. 
Its seat of election is in the center of the face, on the ala? of the 
nose and in the nasogenial grooves; it is less common in the other 
regions of the face and on the vertex, rather rare on the thorax and 
the genitals, exceptional in other kerotic regions. Oily seborrhea 
is observed on the face, on the hairy scalp and sometimes on the 
thorax. 

Its etiology merges with the etiology of kerosis. It is practically 
never observed before puberty. Its relations with sexual develop- 
ment, genital disturbances and gastric affections are very evident. 

The treatment is also that of kerosis. Locally, less reliance should 
be placed on fat-removing washes and lotions, containing ether or 
other ingredients, than on sulphur or camphor, etc. Systematic 
massage of the skin favors the evacuation of the retained products; 
its exaggerated employment would be injurious. 

THE ACNES. 

The term acne has been applied, since Willan, to all eruptions 
which were believed to be due to an affection of the sebaceous 



THE ACNES 385 

glands; the clinical appearance, or the related cause or probable 
character of this affection being specified by an adjective. A reac- 
tion has set in against this linguistic abuse which led to confusion. 

Seborrhea is no longer described as acne sebacea or oleosa; we speak 
of keratosis senilis instead of acne sebacea concreta; acne miliaris or 
milium is a form of epidermic cyst; the acne varioliformis of Bazin, 
or molluscum contagiosum, is an epithelial tumor; acne rosacea 
belongs to the chronic erythemas and its complication ; acne hyper- 
trophica to the hypertrophic dermatoses; acne cornea is a keratotic 
folliculitis; acne, decalvans is a decalvating folliculitis; acne cachec- 
ticorum is a variety of tuberculide as acne syphilitica is a form of 
syphilide. 

There remains a dermatosis which is typical of the genuine acnes, 
namely acne vulgaris or juvenilis; and, in addition, a few related 
varieties. 

Acne Vulgaris or Juvenilis. — This is a very frequent complica- 
tion of kerosis and of seborrhea in particular, manifesting itself 
as a regional, successive, follicular eruption, especially affecting 
youthful individuals. 

Acne is not characterized by a single eruptive lesion, but by a 
polymorphous set of lesions more or less derived from each other; 
comedones, papulo-pustules, superficial or deep follicular pustules, 
indurated abscesses, crusts and cicatrices. Besides the cases with 
perfectly developed lesions, there are very numerous individuals 
suffering from incomplete acne, with a few comedones and, from 
time to time, a papulo-pustule. 

A comedo is a small horny mass, with a brown or black top, the 
size of a pinhead to that of a millet-seed, imbedded in a dilated 
follicular orifice where it resembles a powder grain. It can be 
squeezed out by pressure between two finger-nails, in the form of 
a firm yellowish mass with a black head, followed by a white 
unctuous filament, resembling vermicelli or a black-headed worm. 
Sometimes, "double comedones" are encountered, meaning come- 
dones situated very close together, with a communicating base. 

The comedo results from an ostiofollicular hyperkeratosis; its 
configuration is that of a small cylinder formed by concentric horny 
lamellae ; its exposed surface is colored, not by a deposit of dust, but 
through oxidation of the keratin itself; the cavity from which it 
may be expressed contains microbacilli in large numbers and sebum . 
It resists more or less the escape of the sebum, which is retained 
below; in the face, the demodex folliculorumis not infrequently met 
with. 

Comedones in variable number, at first imperfectly formed and 
hardly distinguishable from seborrheic cocoons, later more volum- 
inous, occur preferably in the face, especially on the nose, the 
25 



386 FOLLICULOSES 

cheeks and the temples, on the chin, the back, the chest and the 
shoulders and rarely elsewhere. 

When they exist alone they constitute acne punctata, the " black- 
heads" of the vernacular. 

A little redness and tumefaction around some comedones are 
characteristic of papular acne. The inflammation is almost invari- 
ably more intense; the red acuminate elevation, the size of a pin- 
head to that of a pea, whitens at its apex in two or three days, due 
to suppuration, the pus may be evacuated or dry up as a crust 
while the papule collapses, becoming transformed into a brownish- 
red spot which leaves a minute cicatrix. This constitutes super- 
ficial pustular acne. It is more or less discrete or confluent and 
occupies the face, the shoulders and the thorax. 

The pustules develop practically without pain and with hardly a 
little itching. 

When the papulopustules have the size of a large pea or a bean 
and are hard, purplish and painful, suppuration being slow but 
deep and abundant, the condition is described as an acne tuberosa 
or indurata. In the form known as phlegmonous acne, the dusky 
red and fluctuating elevations surmount real acneiform abscesses, 
dermic or hypodermic; sometimes there are cavities with oily 
contents. 

These different varieties are often associated in the same patient 
{polymorphous acne) in variable proportion (Fig. 122). In severe 
cases, the face, chest and back may be covered with lesions in all 
stages of development and with countless cicatrices of variable 
size, producing real deformities, so that almost no healthy skin is 
left. Sometimes the eruption has a tendency to become localized 
in one of these regions. 

The topography of acne is very specific; it practically never 
passes below the belt line, nor the upper two-thirds of the arms, 
nor the margin of the scalp, where it invariably stops. 

The eruption is maintained through uninterrupted crops of new 
lesions; it is continuous, but with periods of exacerbation in the 
spring, at the time of menstruation or in connection with errors in 
diet. [It constitutes about 8| per cent, of all cases seen in derma- 
tological practice in Ameria.] 

Etiology and Character. — The condition sine qua non of acne is 
kerosis; individuals having acne always suffer from seborrhea, 
pityriasis simplex and sometimes from eczematides. A predis- 
posed soil is present and persists beyond the acne. 

The eruption begins in both sexes at the approach of puberty, 
flourishes toward the sixteenth and eighteenth year and diminishes 
between the twenty-second and the thirtieth year; it is not uncom- 
monly followed by rosacea, baldness or eczematides. 



THE ACNES 



387 



The causes of kerosis accordingly predispose likewise to acne; in 
the first place, the molimina, genital excitement, functional or 
organic genital disturbances. A very correct observation, fre- 
quently made, is that acne localized on the chin of young girls 
or young women almost certainly indicates some utero-ovarian 
ailment. 

Digestive disturbances, improper diet, gastric dyspepsia and 
habitual constipation play an equally important part. 

A pale complexion, a "lymphatic" or "arthritic" constitution, are 
often met with in acne patients, especially those with a kerotic 
heredity. 




Fig. 122. — Juvenile polymorphous acne. 

As to the determining cause of the eruption, that which trans- 
forms a seborrhea into acne, it is practically certain that this is 
primarily of local microbic, infectious origin. This is not an estab- 
lished fact for comedo, although Sabouraud has shown that the 
comedo contains in its interior myriads of seborrheic bacilli (the 
old acne bacillus of Unna and Hodara), and that in its surroundings 
the bottle-bacillus and cocci are usually present. 

The acne pustule almost regularly encloses, sometimes in enor- 
mous numbers, staphylococci of various kinds, which are pyogenic; 
the pustule is only rarely sterile, 



388 FOLLICULOSES 

From the benign character of this suppuration, its freedom from 
pain, its slow development, it may be inferred that the ordinary 
causative agent is not a virulent staphylococcus, such as the Staphy- 
lococcus aureus, but more probably the Staphylococcus albus or 
the staphylococcus growing in gray cultures, the polymorphous 
coccus of Cedercreutz, or an analogous organism. 

Summarizing, the acne pustule is a folliculitis and perifolliculitis 
of a follicle obstructed by a comedo and infected by a pyococcus of 
moderate virulence. The abscess, resulting from the onrush of 
leukocytes, is primarily situated in the wall of the follicle, under the 
comedo, destroys this wall in a part at least of its circumference 
and more or less deeply invades the perifollicular tissue; this explains 
why it leaves a cicatrix. The sebaceous gland plays only a very 
subordinate part in the process. 

Treatment. — Both local and general treatment are required. 

Locally, the skin must be kept very clean by means of baths 
and warm soapy or alcoholic lotions. Camphorated alcohol, at 
first dilute, camphor and sulphur lotions, sulphuretted or mercur- 
ial washes, or chlorhydrate of ammonia, yield much better results 
than salves of any kind. Mild measures must be employed to 
begin with, for the skin in some cases of acne is extremely irri- 
table. 

After washing with soap, before applying the selected lotion, it 
is advisable to squeeze out the comedones from time to time, by 
systematic massage, pressure with a watch-key, or even by means of 
a special "comedo punch" and to open the superficial pustules 
with a flamed needle. These procedures must not be overdone, 
however, as the eruption is occasionally aggravated in this way. 

In severe and obstinate cases, the rapid exfoliating method is 
recommended; I have repeatedly been enabled to obtain nearly 
complete and durable cures with it. Gradual exfoliation is often 
equally successful, for example with the "strong salve" of Brocq 
(see Therapeutic Notes) which is allowed to act from five to thirty 
minutes before a lukewarm wash or bath. The irritation is then 
soothed by means of a zinc paste. 

In case of indurated or phlegmonous acne, the galvanocautery, 
if necessary the thermocautery, serve to evacuate the purulent 
collections and suppress the developing lesions. Radiotherapy, 
employed as a last resort, sometimes yields very valuable results. 

The internal treatment must aim in the first place at the correction 
of the general hygiene. The diet must be closely regulated, omit- 
ting all stimulants, sweets of all kinds, fermentable substances and 
an excess of meat. The physician must see to the regularity of 
meal hours, good mastication, the condition of the teeth, regular 
evacuation of the bowels, which will sometimes have to be secured 



THE ACNES 389 

by suitable laxatives. Disturbances of the genitourinary appara- 
tus must be corrected as far as possible. Exercise, friction of the 
cutaneous surface and massage contribute to regulate the general 
circulation. 

L. Jacquet advocated, besides bradyphagia, "massage of the 
face by petrissage" and facial gymnastics; these measures often 
prove really efficient. 

The remedies to be recommended are, according to the cases and 
sometimes successively, arsenic, cod-liver oil, ferruginous agents, 
ichthyol, beer-yeast and lactic ferments; the latter are sometimes 
highly successful, sometimes entirely inefficient. Staphylococcic 
vaccintherapy, or better, inoculation with a mixed autovaccine, may 
likewise have excellent results or in other cases prove useless. 

[In my experience, juvenile acne may be successfully treated by 
local measures alone without any regard to the general health. 
Proper exercise, regular bowel movements and a diet free from 
excesses of all kinds are good for every one but I have never been 
able to clearly establish a relationship between juvenile acne and 
any general abnormalities whatever. One of the most severe and 
most obstinate cases of acne I have ever encountered occurred in 
an otherwise perfect specimen of young manhood who lived at the 
trainer's table and observed the severe regimen required of a mem- 
ber of a college athletic team. 

My plan of treatment consists of various measures of local anti- 
septics: washing with soap, avoidance of friction with the towel 
which serves to spread infection, soaking ten to fifteen minutes 
with a 1 to 2000 weak alcoholic watery solution of bichloride of 
mercury (the soap must be thoroughly rinsed off first) and, after 
washing away the bichloride solution and drying, an application of 
sulphur paste, i. e., zinc oxide ointment containing 10 per cent, of 
kaolin and 10 per cent, of precipitated sulphur, to be applied at 
bed-time. In the morning a soap and water wash. The kerato- 
lytic action of the paste becomes obvious after five to ten days; the 
skin feels tight, drawn, as if coated with varnish. This symptom 
is the signal for omitting the sulphur paste one night and applying 
instead a soothing and softening cream consisting of 2 per cent, 
salicylic acid in cold-cream or petrolatum. The next night the 
paste may be resumed and thereafter must be interrupted by one 
night of the cream every fourth or fifth day. At the same time 
it is of primary importance to remove mechanically as many sources 
of infection as possible; comedones must be squeezed out and 
pustules evacuated systematically at intervals of three, later seven 
to ten days. My own experience with vaccines has not been 
favorable; others, notably Gilchrist and Engman have reported 
excellent results.! 



I'.MI 



FOLLICULOSES 



Medicinal and Occupational Acnes. -These are closely related to 
juvenile acne and if proof were required, would show the part 
played by the ingesta as well as 1»\ external irritants in the genesis 
of this skin disease. 

The iodides and, to a less degree, the bromides produce in some 
individuals, either from the start or after prolonged administration, 
an iodide or bromide acne; it- special features are the age of the 
patient-, the sudden onset and the inflammatory indurated nodu- 
lar character of the eruptive lesions. These acnes are localized 
chiefly on the face and the hack and may become associated with 
other symptoms of iodism or bromism. 




Fig. 123. — Cade oil acne; internal aspect of the right thigh in a case of psoriasis 
treated with an nil of cade glycerolate. The pustules contained the Staphylococcus 

aureus; cured by means of a soapy salve. 



The various preparations of tar. oil of cade in particular, give 
rise in those who handle them or apply them to the -kin (in the 
treatment of psoriasis, for example i to an eruption of reddish- 
brown papulopustules, centered by a comedo, very much like acne 
(Fig. 1-':;). 

Mineral oil-, employed for the lubrication of engines, may cause 
either acute suppurative folliculitides or subacute acneiform fol- 
liculitides, analogous to tar acne. All these hydrocarbons act 
apparently by producing an ostio-follicular hyperkeratosis, which 
retains the pyococci and creates conditions favorable to their growth 
and to an inflammatory reaction of the integument. 

Chlorin acne presents the features of juvenile acne, although 
greatly exaggerated, with an extraordinary profusion of comedones 
and a general distribution over regions which escape in common 



The acnes 39 i 

acne; it has been observed in laborers employed in sodium chloride 
electrolytic works. According to Fumouze (1901) it is due to 
nascent sodium hypochlorite. 

Acne Necrotica of Boeck (Acne Pilaris of Bazin, Acne Varioli- 
formis of Hebra, Frontalis, Rodens, etc.) . — This is a disease affecting 
middle-aged and old persons and presents characteristic lesions. 

The eruption consists of pink or waxy papules the size of a pin- 
head to that of a small lentil, whose apex very rapidly assumes a 
yellowish hue, simulating a vesico-pustule and dries to a biconvex 
brownish-yellow crust; this very adherent crust is embedded in 
the skin and encircled by a sometimes slightly raised border; its 
fall is often delayed and leaves an indelible depressed cicatrix. 

Advancing in continuous or intermittent crops, the eruption is 
situated on the forehead, at the border of the scalp which is often 
in part invaded, at the temples, in the conchae of the ears, some- 
times on the nose and in the nasogenial grooves and very rarely on 
the middle of the back and the chest. The lesions are grouped or 
disseminated. The affected regions finally become riddled with 
cicatrices. When left untreated, the affection lasts for years and 
even indefinitely. 

The histological lesion consists of a dry lenticular necrosis, situ- 
ated at the orifice of a follicle and comprising the entire thickness 
of the epidermis and a superficial portion of the cutis; surrounded 
by an inflammatory zone with thrombosis of the bloodvessels. 

Necrotic acne is distinguished from crusted secondary syphilides 
by its necrotic character and its cicatrices; from tuberculo-crusted 
tertiary syphilides, by the absence of induration and by the dis- 
semination of the lesions. 

Only the microbacillus of seborrhea and various staphylococci, 
especially the aureus, have ever been discovered in this acne; it 
is probable that another etiological factor is involved, but it is 
unknown. Kerosis and seborrhea constitute the necessary soil. 

Appropriate treatment ensures a cure in a few days. The 
employment of soap and water and of a strong sulphur-cade- and 
salicylic-acid salve is sufficient; all internal medication is unneces- 
sary. Sulphur washes or a sulphur salve are recommended for 
the prevention of recurrences. [I have found soap and water and 
the application of ammoniated mercury ointment, which is not 
unpleasant, quite sufficient for a cure.] 

Keloid Acne. — This affection, first described by Bazin — identical 
with the dermatitis papillaris capillitii of Kaposi — occurs essentially 
in males and is almost exclusively observed at the nape of the neck, 
at the border of the hairy scalp and very rarely in the beard. 

It begins as an acuminated papular folliculitis, the size of a millet 
or hemp seed, which may become pustular; originally disseminated, 



392 FOLLICULOSES 

the lesions multiply and become grouped, finally coalescing into a 
band which occupies the entire posterior border of the scalp. 

This folliculitis is distinguished from the start by its subacute 
infla.TTiTn fl.tnry character, its very marked induration and a course 
Leading to the formation of fibrous excrescences. 

The confluence of these lesions results in a horizontal row of 
agglomerated fibrous tubercles and finally a "cushion" which may 
have the thickness of a finger, a length of 10 to 15 cm., or even 
extend from one ear to the other. Cicatricial and smooth on its 
lower aspect, this cushion bristles on its upper side with hairs 
arranged in tufts or wisps. On pulling these out, one is surprised 
by the depth of their implantation. 

The duration of the affection is indefinite; it may be prolonged for 
fifteen to twenty years, or longer. The cushion slowly extends 
upward on the occipital region, never in a downward direction, and 
leaves behind it a pinkish, more or less thickened permanent cicatrix. 

Histology shows a chronic follicular inflammation, noteworthy 
in that the cellular infiltration is almost exclusively composed of 
plasmocytes, with a few giant cells; it leads to the formation of a 
dense hyperplastic fibrous tissue; the process is absolutely different 
from that of the true keloids, as shown especially by Pautrier and 
J. Gouin. Its nature is not known and the special microbic agent 
which is probably present has not been demonstrated. The co- 
existence of kerosis is invariable. 

Keloid acne is very obstinate to treatment. Antiseptic washes, 
iodin applications, mercurial ointments, sulphur, naphthol and tar 
salves are indicated only in the first stage and are rarely sufficient. 
The best obtainable results are secured by the following method: 
First, all the active lesions of folliculitis are destroyed with a fine- 
pointed thermocautery; then the keloid growths are attacked by 
very deep and repeated scarifications, followed eight or ten days 
later by a number of radiotherapeutic sessions. 

In well-marked cases, surgical removal is advantageously per- 
formed, followed by radiotherapy. Extirpation alone is not to be 
recommended as it is often followed by recurrence. 

CICATRICIAL DEPILATING FOLLICULITIDES. 

The nosographical group of depilating folliculitides, or acne 
decalvans, is indefinitely outlined and its varieties are still imper- 
fectly formulated for lack of knowledge of the etiological factors. 
All the dec]) folliculitides may become depilatory through perma- 
nent atrophy of the follicle, as in furuncle, favus, keratosis pilaris, 
sycosis, the acnes and the syphilides. But those under present 
consideration arc inflammatory, sluggish, progressive, rebellious, 



CICATRICIAL DEPILATING FOLLICU LI TIDES 



393 



often agminated and necessarily leave true cicatricial tissue behind 
them; they are the forms which lead to the cicatricial alopecias. 

Pseudo-pelade of Brocq {alopecia atrophicans of foreign authors) 
represents the most typical form. It is characterized by alopecic 
and cicatricial spots or patches, scattered or grouped on an other- 
wise healthy scalp. These spots have various dimensions and 
shapes, being sometimes barely lenticular, rounded and very 
numerous; sometimes several centimeters in diameter, irregular, 
with geographical outlines; or the two varieties may be associated 
(Fig. 124). The borders are distinct, without a transitional zone; 
the surface is wax-white or faintly pink, perfectly smooth, without 
scales or broken or lanugo hairs; even the follicles have disappeared, 
as may be ascertained by painting the surface with tincture of 
iodin. 





wF & 








W m • 




nj Ik 








H 


-J 


L •• 







Fig. 124. — Pseudo-pelade of Brocq. 

This affection is met with on the hairy scalp of youthful or adult 
individuals, especially in men and rarely in the beard. The medium- 
sized and large spots are evidently the result of growth and con- 
fluence of small spots. The onset is insidious and usually escapes 
notice; Dreuw believes that it takes place in childhood as an alopecia 
parvimaculata. 

In watching the progress of the affection, which is extremely 
slow, it is seen to begin with a slight orificial keratosis at one or 
several hairs surrounded by a pinkish area, at the border of the 
patch; next follows the definite loss of these hairs and the extension 



394 FOLLICULOSES 

of the cicatrix to this area. Despite all efforts and despite the prob- 
ability of a parasitic cause no special fungus or microbe has ever 
been found in the hairs or in the follicles. Under the microscope a 
cellular infiltration is seen around the follicles and around the blood- 
vessels and lymph vessels which are greatly dilated; the process 
terminates in a connective-tissue and elastic atrophy. It is certain 
that pseudo-pelade must be considered as a folliculitis, but it will be 
noted that the follicular inflammation is clinically not very evident, 
far less so than in the following forms. 

The differences between pseudo-pelade and ringworm are con- 
siderable. There is a much greater analogy with the cicatrices of 
favus, so much so that in my opinion the disease would be better 
designated pseudo-favic alopecia, but there have never been yellow 
pits or scutula, the cicatricial skin is not so red, the hairs are not 
dull and lusterless and there is no fungus. The patches of lupus 
erythematodes are less numerous and the process extends in the 
form of very red and hyperkeratotic spots. 

By means of sulphur lotions, sulphur, cade, naphthol, resorcin 
salves, mercurial ointments, etc., one may hope to arrest the 
progress of the disease, but not to restore the hairs whose follicles 
have been destroyed. The treatment should therefore begin as 
early as possible. 

Folliculitis Decalvans. — Folliculite epilante of Quinquaud — acne 
decahans of Lallier — is perhaps merely a variety of the preceding 
type from which it differs only by the presence in the invaded zone 
of a few scattered pustular follicles, the size of a pinhead or a small 
pea. 

Lupoid Sycosis of Brocq. — Lupoid acne of American writers, 
ulerythema sycosiforme of Unna, dermatitis sycosiformis atrophicans 
of Ducrey and Stanziale, is situated on the beard and especially on 
the cheeks (Fig. 125). It gives rise to agrainated follicular pustules, 
with inflammatory redness and diffuse superficial infiltration of the 
skin. 

It differs from ordinary sycosis by its tendency to extend uni- 
formly and by the red, smooth, central cicatricial alopecia, often 
of a keloidal appearance, which it leaves behind. It may greatly 
resemble a flat lupus vulgaris in course of central cicatrization; 
but there are no lupomas and only suppurative folliculitis. The 
single focus, or at most two or three foci, in the course of years may 
attain the dimensions of the palm of the hand. 

Depilating follicvlitides of the smooth parts, described by Arnozan 
and Dubreuilh, which occupy the thighs and legs, are still more 
rare; they constitute a type related to the above or perhaps a form 
of tuberculides. 

Furthermore, an entire series of cases of necrotic (Janovky) or 



SUB A C V TE FOLLIC VLI TI DES 



395 



ulcerative (Bizzozero) jolliculitid.es or perifolliculitides has been 
reported; their significance and nosological position have not been 
determined. 

Treatment. — Washes with alcohol or sublimate, yellow oxide 
salves and mercurial plasters, combined with epilation, have long 
been the best means for combating the progress of lupoid sycosis 
and analogous affections. Radiotherapy is greatly superior to 
these measures and vields note worth v results. 




Fig. 125. — Lupoid sycosis. 



SUBACUTE FOLLICULITIDES. 

There exists a group of red folliculitides, of acute or rather sub- 
acute course, which are neither regularly suppurative nor necessarily 
depilatory. 

Follicular Eczematides. — I employ this term for the peripilar 
seborrheids of authors. The acute form manifests itself especially in 
markedly kerotic men, preferably at the beginning of the warm 
weather, in the form of an eruption of small red acuminate follic- 
ular papules, agminated in one or several patches on the back, the 
shoulders or the anterior side of the trunk. The patch extends by 
invasion of all the neighboring follicles, while at the center the 
eruption subsides and leaves behind a yellow slightly desquamating 
surface. The course is rapid at the onset. The diseased surface 
attains the size of the hand in the course of a week or two; later on 
it is sluggish. 



396 



FOLLICULOSES 



A subacute form of this affection has been frequently described. 
It is characterized by small spots of a yellowish red, or a purplish 
red, perifollicular, barely papular, arranged in groups of ten to 
thirty, which gradually become more prominent and covered with 
a yellowish scale or crust (Fig. 126). Continence of these lesions 
may lead to the production of spots of figured eczematides. 

Their scat of election is, moreover, the same as that of the figured 
eczematides which may have preceded the follicular eruption. The 
latter is frequently seen also on the limbs, the thighs, the legs, the 
wrists, the forearms, etc. Pruritus is very slight. 




Treatment with sulphur baths, sulphur or ichthyol salves, is very 
promptly effective in the acute form; it must be more energetic or 
more prolonged in the sluggish varieties. 

Eczema Folliculorum of Malcolm Morris and Unna is, I believe, 
merely a rare variety of the preceding affection. It consists of a 
non-suppurative folliculitis, agminated in small red patches, which 
are distributed on the trunk and especially on the limbs, progres- 
sing extensively, with a tendency to complete eczematization. 
Pruritus is sometimes rather troublesome and causes scratching. 
This form is somewhat rebellions to treatment. 

Follicular Syphilides. Among the papular secondary syphilides, 
there is a form with small papules, known as miliary, granular, 
lichenoid, or acneiform peripilar syphilides. They result from a 
localization of the syphilitic infiltration around and beneath the pilo- 



SUBACUTE FOLLICU LI TIDES 



397 



sebaceous follicles; it usually seems to be invited by a preliminary 
lesion of these follicles, in the form of kerosis or of keratosis pilaris. 
The follicular syphilides usually make their appearance from four 
to eighteen months after the chancre; this is therefore a secondary 
manifestation but not one of the earliest. A distinction is made 
between a papulo-squamous, papulo-pustular and even a vesicular 




Fig. 127, 



-Follicular syphilides, papulo-squamous variety. On the face the eruption 
was distinctly papulo-lenticular. 



variety. The eruption is disseminated but very often consists of 
small groups of agminated lesions (Fig. 127). Its seat of election is 
on the trunk, where it is seen on the back, flanks and loins; the 
limbs may also be involved. 

The papulo-squamous variety consists of small miliary elevations, 
of a dusky red color, acuminate and crowned with a dry scale 



398 FOLLICULOSES 

which is enclosed in the follicular orifice and not easily removed. 
The principal features of these lesions are their firmness, so that 
they feel like granules to the finger and their relatively slow devel- 
opment; they persist several weeks without change. 

The papuh-pustular variety may become combined with the 
preceding in the same eruption, or it may exist alone; it is often 
very diffuse and abundant. The dark-red perifollicular protuber- 
ance is larger than in the squamous variety, even lenticular in size; 
it is surmounted by a vesico-pustule, always containing much less 
fluid than one would expect, rapidly drying into a crust. Under 
the vesicle or the crust is seen a dilated, sometimes eroded follicular 
orifice. 

According to the size and appearance of the papulo-pustules or 
papulo-vesicles, the terms of acneiform, varicelliform, herpetiform, 
varioliform syphilides have been employed (A. Fournier). There 
occur transitional cases between this variety and the papulo-crusted 
or ulcerative syphilides. 

Whether squamous or pustular, these syphilides may in some 
cases become arranged in rings, or grouped in collections of about 
fifteen to at most fifty lesions, sometimes around a large lenticular 
or crusted papule. These agminated efflorescences, absolutely char- 
acteristic of syphilis, have been picturesquely described as syphilides 
en bouquets and corymbiform syphilides. 

Careful study of the features of the eruption and the concomitant 
symptoms will guard against confusion of follicular syphilides with 
keratosis pilaris, follicular eczematides, pityriasis rubra pilaris, or 
with acne, papulo-necrotic tuberculides, etc. The differential diag- 
nosis from lichen scrofulosorum may be much more difficult even 
with the help of a biopsy, for their structure is rather commonly 
tuberculoid, but there is a positive Wassermann reaction. 

The follicular syphilides are tenacious, rebellious to treatment, 
often leave persistent brownish macules, and have a tendency to 
recurrence. Treated with mercury, they last six weeks or longer; by 
means of arsenobenzol they can be removed in two or three weeks. 

Follicular Tuberculides. — I have previously discussed the lich- 
enoid tuberculides with small acuminate and peripilar lesions, which 
belong under the heading of lichen scrofulosorum. 

The papulo-necrotic tuberculides seem to be so evidently related 
to the follicles that their first description by Barthelemy was given 
under the names of folliclis and aortitis. Histological examination 
serves to confirm the clinical impression in this respect. It would, 
therefore, be justifiable to group them among the folliculoses; at 
any rate, the question of their differential diagnosis from follicular 
affections is constantly raised. Their follicular localization is really 
accidental, however; it is sufficient proof to point out that these 



PITYRIASIS RUBRA PILARIS 399 

tuberculides very commonly affect the palmar region, where follicles 
are absent. The reader is therefore referred to another chapter 
for this description. 

PITYRIASIS RUBRA PILARIS. 

Devergie, E. Besnier and Richaud have described under this 
name a skin disease distinct from psoriasis, from genuine pityriasis 
rubra [Hebra] and from lichen planus, in spite of a few real analogies. 
On the other hand, Hebra and Kaposi have studied under the name 
of lichen rubra acuminatus an eruption resembling it to such a 
degree that at the International Congress, Paris, 1889, the identity 
of the two pathological types was admitted ; Kaposi himself empha- 
sized this identity. It is desirable, however, to reserve the name 
of lichen acuminatus only for the acuminate forms of Wilson's 
lichen, which are, however, very rare. 

The characteristic lesion of pityriasis rubra pilaris is a small 
squamous follicular papule. It is of a bright or dull red color, or 
pinkish, sometimes colorless at first, prominent, of acuminate 
shape with a conical apex which bears a follicular orifice covered 
by an adherent, dry, white scale, enclosing one or more often 
atrophied and shrivelled lanugo hairs. These follicular papules are 
dry; they are never seen to be vesicular or pustular; their size is 
that of a pin-head or a millet-seed; they are firm to the touch and 
as a result of their distribution the skin takes on a granular appear- 
ance and has the feeling of a grater when scrubbed with the hand. 

Isolated at first, these papules multiply and become agminated 
later on; the intermediate skin becomes reddened and there follow 
thickened spots, patches, or surfaces, of all dimensions, of a yellow- 
ish-pink color, covered with pityriasic or psoriatiform, sometimes 
granular scales, dotted with horny points or quadrilated and lichen- 
ized. Their borders are, as a rule, irregular, dentated and sur- 
rounded by characteristic peripilar papules (Fig. 128). 

The eruption is usually distinctly symmetrical. Its distribution 
is fairly constant in fully developed cases and presents itself under 
typical aspects in the affected regions: the scalp, as a pityriasis 
with abundant white scales; the hairs do not fall out; on the face, 
no pilary cones are seen, but a diffuse scaly redness, with tension 
of the skin, even ectropion, or a chalky appearance, with greasy 
crusts on the eyebrows and in the nasogenial grooves; on the 
elbows and knees, red patches are observed with thick, adherent, 
roughened scales, less sharply limited than those of psoriasis. 

The dorsal surface of the phalanges, even more than the last- 
named regions is a seat of election of pityriasis pilaris; sometimes 
red papules agglomerated in patches are seen; in other cases only 



400 



FOLLICULOSES 



blackish horny cones at the pilary orifices; these lesions are almost 
pathognomonic. The nails are striated. 

The palmar and plantar regions are of a dusky red color; their 
horny layer is thickened, dry, fissured at the folds, sometimes des- 
quamating; the transition into healthy skin is gradual, imperceptible. 

The limbs and often also the trunk, are the seat of more or less 
grouped, acuminate papules and patches or thick and scaly sur- 
faces, which may cover large stretches, almost the entire body, 
although a few localities at least are always exempt. The healthy 
-pairs are angular and limited by concave curves. 



Fig. 128. -Pityriasis rubi 
five years; the al 




Anterior surface of the thigh; man aged twenty- 

•alized eruption dated hack three years. 



The patients sometimes complain of itching or heat and usually 
of a sensation of tension. 

The course of pityriasis rubra pilaris is very variable. At the 
onset, the palmar and plantar regions, or the elbows and knees, 
or also the dorsal aspect of the phalanges and the hairy scalp may 
be alone affected for a period of months or years. So-called abor- 
tive cases are therefore frequently met with. Sometimes, follicular 
papules, grouped on the limbs or on the trunk, are the only demon- 
strable symptom. 

As a rule, the more or les> prolonged periods of invasion and 
confluence arc interrupted by long stationary stages. Sudden 
extensions, as in exfoliative erythroderma, are likewise noted. 



FOLLICULAR KERATOSIS 401 

The histological lesions consist essentially of a laminated hyper- 
keratosis of the follicular infundibulum, composed of horny plugs, 
around a hair which is preserved or atrophied or broken off short. 
The granular layer persists and is sometimes even hypertrophied. 
The rete is thinned or slightly thickened, sometimes stretched. 
The congested papillary body presents a variable degree of cellular 
infiltration, often rather scanty and diffuse. There is nothing 
to suggest psoriasis or lichen. 

The nature of the disease is shrouded in mystery. It is known 
to occur at any age, especially during adolescence and youth, the 
male sex being somewhat more frequently affected, but its etiology 
is entirely unknown. 

In December, 1906, Milian suggested a tubercular origin of 
pityriasis rubra pilaris, on the ground of: (1) The remarkable 
frequency of tuberculosis among these patients; (2) the existence 
of intermediate cases between lichen scrofulosorum, true tuber- 
culides and pityriasis rubra pilaris; (3) the positive tuberculin 
reaction which is obtained in cases of pityriasis pilaris. But these 
proofs are not sufficiently convincing. Since that time, some 
confirmatory cases have been observed and a goodly number of 
others which do not harmonize with this interpretation. It is 
therefore still an open question whether or not pityriasis rubra 
pilaris should be regarded as a perifollicular tuberculide, related 
to lichen scrofulosorum and akin to the pityriasis rubra of Hebra- 
-ladassohn. 

The diagnosis is often very easy; in doubtful cases, confusion 
may possibly occur with other peripilar skin diseases, especially 
keratosis pilaris rubra and lichen spinulosus, or with the erythro- 
dermas, with psoriasis and with lichen planus. 

The classical treatment heretofore has been that of psoriasis: 
baths and soap, with arsenic and tonics internally. In view of the 
possible tubercular character of pityriasis rubra pilaris, emphasis 
must be placed on hygienic measures, fresh air, strengthening food, 
cod-liver oil. Milian was impressed with the remarkable improve- 
ment produced by injections of tuberculin. I have employed them 
together with injections of novarsenobenzol and have obtained 
encouraging but inconstant results. An attempt should also be 
made with radiotherapy. [I have found the .r-ray entirely useless.] 



FOLLICULAR KERATOSIS. 

In the folliculoses of this kind, the inflammatory character is 
well-nigh obliterated; some of them may be considered as mal- 
formations. 
26 



402 FOLLK CLOSES 

Keratosis Pilaris Simplex. — This disease, also known as lichen 
pilaris (Bazin), cacotrophia folliculorum (T. Fox), ichthyosis anserina 
scrofulosorum, xeroderma pilaris, is extremely common. Nearly 
one-third of all individuals of both sexes suffer from it to some 
degree; it is hereditary in many otherwise healthy families. 

This fact easts a doubt on the relationship of this affection to 
scrofula; it cannot be simply dismissed as a tuberculide. Its rela- 
tions with ichthyosis, which practically always accompanies ostio- 
follicular keratosis, are on the contrary obvious. 

Keratosis pilaris appears toward the age of two or three years, 
flourishes between fifteen and twenty and subsides at an adult age. 
Mild cases are the most common. 

It usually occupies the external surface of the arms and thighs, 
often also the calves, the lower part of the legs, the forearms, elbows 
and knees, the waist and the hips, sparing fatty and moist regions. 

The symptoms consist of dryness of the skin with roughening due 
to more or less marked acuminate papular elevations; these are 
follicular orifices filled with a very adherent grayish horny cone, in 
which the downy hair is rolled up as a spiral. The color of the 
integument is sometimes normal; in other cases, of more severe 
type, the follicular constituents are red or purplish, representing 
keratosis pilaris rubra. 

In the course of time, the shrivelled hairs disappear, the elevations 
become flattened and transformed into punctiform cicatrices. 

Although of the nature of deformities of embryonic origin, like 
the nevi, keratosis pilaris takes a course which leads to total atrophy 
of the affected follicles and their sebaceous gland and to alopecia 
of the invaded regions. 

Young girls or young women frequently seek advice on account 
of the roughened condition and red dots on their arms. The same 
internal medication is recommended as for ichthyosis. Locally, it 
is advisable to avoid pumice stone and rubbing with alcohol, but 
the skin should be kept anointed with a fatty substance, a soapy 
salve, vaselin, or glycerol of starch containing salicylic acid. From 
time to time, the skin should be cleansed with green soap; [a salicy- 
lated eucerin salve is useful]. 

Keratosis Pilaris Rubra Atrophicans of the Face. — This affection, 
named folliculitis rubra by Wilson, ulerythema ophryogenes by Unna, 
was studied by Brocq, who pointed out its connection with keratosis 
pilaris simplex. It is observed in youthful or adult individuals, 
preferably in males. 

It is situated on the eyebrows, especially at their outer third, 
on the lower portion of the forehead and in the parotid region; 
furthermore, it is not infrequently combined with simple keratosis 
pilaris in the elective territories of the latter. It is characterized 



FOLLICULAR KERATOSIS 403 

by a diffuse redness, with a granular surface due to the acuminate 
elevations of the pilary orifices, from which protrude scanty and 
deviated hairs. Later on, the affected surfaces become bald and the 
beard especially grows only very scantily; moreover, fine cicatricial 
spots are seen, sometimes in an anastomotic network. 

The atrophic tendency is therefore more pronounced than in 
simple keratosis. Brocq has pointed out the kinship between this 
keratosis rubra pilaris of the face and moniliform aplasia; the two 
affections may coexist. 

In pilary keratosis of the face, which is very obstinate, the con- 
dition may be improved by repeated applications of green soap; 
red oxide ointment is equally successful. Crossed linear scarifica- 
tions may be indicated. 

Lichen Spinulosus. — Under this name, first used in England, 
several skin diseases of unknown and probably different character 
have been described. Their characteristic symptom consists in the 
presence of more or less long and dry, filiform horny protuberances 
emerging from the pilo-sebaceous orifices which are themselves 
slightly raised and of normal or faintly pink color. 

The lesion is encountered in youthful individuals and occupies 
diffusely the face, or the neck, or the limbs, or the buttocks (acne 
cornee of French authors) ; or it may be arranged as circumscribed 
patches on the trunk and the buttocks (acne keratique of Tenneson) ; 
or it appears ia little children and covers large surfaces (lichen 
spinulosus of R. Crocker and Adamson). 

The duration of this dermatosis is variable; several times it has 
been known to disappear spontaneously in a few weeks or months. 
In one case I have found large numbers of demodex in the affected 
follicles. 

Analogous horny protuberances may be observed in lichen scrof ulo- 
sorum, in the peripilar syphilides, etc. It must therefore be kept in 
mind that the spinulation is not the pathognomonic sign of a single 
and always identical affection. 

Ichthyosis Follicularis. — This term and that of keratosis follicu- 
laris have been employed by various writers to designate actually 
non-classifiable affections which resemble either psorospermosis fol- 
licularis but without dyskeratosis, or ostiofollicular hyperkeratotic 
nevi, etc. A familial and contagious form has been described by 
Brooke. 

In the differential diagnosis of these various follicular keratoses, 
it must be remembered that lichen planus may exceptionally assume 
the form of acuminate papules ; that pityriasis rubra pilaris includes 
numerous incomplete, entirely localized cases; that spinulation is 
encountered in several diseases; finally, that the follicular syphilides 
are sometimes discrete and often very polymorphous. 



CHAPTER XX. 
TRICHOSES. 

The name "trichoses" (0pi£, t P lx6s = hair) is applied to the 
diseases and anomalies of the hairs on the head and body. 

The hairs are filiform corneal structures whose root is inserted 
in the pilary follicles; they are a secretory product of the terminal 
papilla of these follicles which they cover with their enlarged 
extremity, known as the bulb. This bulb is hollow while the hair 
is still growing; it closes up and becomes solid when the hair has 
completed its development and is ready to fall out. When a hair 
has fallen out or been forcibly removed, unless the deep portion of 
the follicle has been destroyed, it is replaced as a rule by another 
hair, which forms in a diverticulum of the original follicle. 

The structure of the hairs is very simple. They consist of more 
or less pigmented elongated corneal cells, forming what is known as 
the cortex of the hair; of an external cuticle; and of a central medul- 
lary canal, which may be absent. 

Under the heading of trichoses belong: (1) the hypertrichoses; 
(2) the hypotrichoses or alopecias; (3) the dystrophic trichoses; (4) 
the parasitic diseases of the hairs. 

Obviously, it would be logical to group the majority of the trichoses 
with the folliculoses. As a matter of fact, a pilary hypcrproduction 
or an alopecia is the manifestation of a trophic disturbance of the 
papilla of the hair; in the tineas, the parasites attack simultaneously 
the root of the hair and its sheaths. But this follicular lesion is not 
apparent; the striking feature consists in the malformation, fall, 
absence or alteration of the hairs. In accordance with the plan of 
this book I shall therefore devote a special chapter to the trichoses. 

HYPERTRICHOSES. 

Hypertrichosis, an anomaly consisting in an overproduction of 
hairs which are larger, more abundant and more highly pigmented 
than is appropriate for the affected region or the age and sex of the 
subject does not always represent the same type of disease. Some- 
times, it accompanies congenital hyperkeratosis. The pure eases 
should be grouped, as already indicated by Virchow, into three 
classes, between which intermediate forms are encountered. 



H YPER TRW HOSES 



405 



1. Nevl yilosi are very common, often multiple, small and lentic- 
ular, or very extensive and may cover large areas (Fig. 129, A) 
Even when they are not verrucous, the skin is usually pigmented and 




-Three types of hypertrichosis. A, nevi pilosi; B, hypertrichosis fetalis; 
C, true hypertrichosis of masculine type. 



nevus cells may be found in it. They are as a rule sharply circum- 
scribed. Their arrangement is not perfectly symmetrical. They 
may develop after birth. 



406 TRtCtiOSES 

2. Hypertrichosis fetalis or lanuginous pseudohypertrwliosts of 

Bonnet —is seen in so-called wild men or human canines and consists 
in the abnormal persistence of the fetal hairs which, moreover, are 
hypertrophied. It is symmetrical, increases with age, occupies 
regions which even in persons with a very strongly developed hairy 
system are rather smooth, like the forehead and the nose. The 
hairs are wooly, soft and curly. The affected individuals usually 
present serious dental anomalies. Yirchow designated this form as 
hypertrichosis of fin' edentata (Fig. 12!) B). 

3. True hypertrichosis must be considered separately in the two 
sexes. 

In men it is merely an exaggeration of the normal state which is 
itself extremely variable. It does not really manifest itself until 
puberty which may be premature. Together with an abundant 
hairy growth of the beard and other hairy regions, an almost ape- 
like hairy proliferation may appear symmetrically on the chest, 
back and limbs; sometimes the hypertrichosis predominates in 
the sacral region, forming the tuft which the ancients considered as 
an attribute of the fauns. 

Masculine hypertrichosis is not uncommonly hereditary or 
atavistic. It has been observed to occur not infrequently in tuber- 
culous individuals. 

In women, hypertrichosis of the masculine type constitutes the 
form which is of chief interest to the dermatologist. 

The patients are usually young girls or young women who have 
noticed since puberty, first the development of a troublesome downy 
growth, followed by hypertrophied hairs on the upper lip, the chin, 
or the cheeks and more rarely by complete beards made up of 
15 to 20 thousand hairs (Fig. 129, C). In some eases, the chest, the 
breasts, or the limbs are the seat of this abnormal hairy growth. 

These hypertrichoses of young girls not unfrequently is the 
occasion of a real pathological obsession, known as trichomania, 
which plunges them into despair and melancholia, even in cases 
where the down is hardly disfiguring. 

Much more common is the appearance of large hairs on the chin, 
or of a moustache in women of thirty to forty years or especially 
at the time of the menopause. 

The cause of this deformity is sometimes hereditary; a natural 
tendency is apt to become aggravated by local irritations, the 
employment of depilatory pastes or of the razor and especially by 
epilation with the forceps. On the other hand, there undoubtedly 
exists a possible, but actually very inconstant relation between 
hypertrichosis of the masculine type and the genital functions. 

This relation is indicated by eases of precocious menstruation and 
sexual maturity in hypertrichotie individuals on the one hand and 



ALOPECIAS 407 

on the other by the hypertrichosis of the menopause. Lesser 
observed a girl of six years who had menstruated since the age of 
three, had the breasts of an adult female and was more hairy than 
a man of thirty years. 

In both sexes, repeated local irritation, scratching, phototherapy, 
etc., may give rise to regional hypertrichoses. Other cases are of 
kerotic origin. 

According to observations made in the course of the war, by G. 
and M. Villaret and others, a hypertrichosis which develops on the 
cutaneous territory of a traumatized nerve generally coincides with 
hyperidrosis and with the absence of the reaction of degeneration 
and indicates an incomplete injury, not a definite lesion of the nerve. 
Inversely, a hypotrichosis originating under the same conditions is 
usually accompanied by the reaction of degeneration and indicates 
a complete interruption of the nerve. 

Treatment. — The question of treatment arises only in cases of 
hypertrichosis in young girls and women. At the onset, it is especi- 
ally necessary to forbid all local irritations and especially epilation. 

Too plainly visible downy hairs may be bleached with strong 
hydrogen peroxide solutions after all fat has been removed, or a 
peroxide cream may be prescribed. A salve made with thallium 
acetate (1 per cent.) will cause a large proportion of the hairs in 
the medicated region to drop out, but has the disadvantage of under- 
going absorption and thereby acting at the same time on the hairy 
scalp and the eyebrows. 

When the hairs are really excessively large no recourse is left but 
electrolytic epilation, which is radical, not particularly painful, 
leaves hardly visible cicatrices when properly performed but is 
very tedious when the hairs are at all numerous. For the technic, 
the reader is referred to special contributions, especially by Brocq, 
who has carefully investigated this question. 

Radiotherapy is often demanded by these patients, but cannot 
at present be recommended. 

Outside of the hairy scalp, its epilating action is unreliable and 
too dangerous to employ; in large doses, it exposes to very unde- 
sirable pigmentations and incurable spots of radiodermatitis 
atrophicans developing after a few years. In weak doses, a renewed 
and sometimes exaggerated growth may be expected after a variable 
length of time. 

ALOPECIAS. 

The term alopecia {aKccivr]^ = fox) is indiscriminately applied 
to the fall of scalp or lanugo hairs (defiuvium) , to the resulting 
hairlessness and even to the congenital absence of hair. 

The congenital alopecias [atrichia] are very rare and often familial ; 



408 TRICHOSES 

in their distribution they are diffuse or regional and occasionally 

circumscribed. The piiary agenesia may be pure, or essential; or 
it may be associated with nevi, congenital hyperkeratosis, keratosis 
pilaris, monilethrix, more or less pronounced cutaneous atrophy, etc. 

The acquired alopecias are divided into two classes, according to 
their being diffuse and regional, or on the contrary circumscribed. 
The hairy scalp is their seat of predilection and, unless otherwise 
indicated, the following remarks will deal particularly with this 
region. 

Regional and Diffuse Alopecias. — Traumatic Alopecias. — Certain 
traumatic alopecias are diffuse. The scalp or body-hairs may have 
been pulled out, accidentally, with a therapeutic object or for 
purposes of simulation. The name trichotillomania designates a 
sort of tic or bad habit which causes some persons incessantly to 
pull or tear out the hairs of a given region. 

Contusions and wounds give rise only to circumscribed alopecias. 
But the rubbing of the head on the pillow, especially at the occipital 
and parietal prominences in some weakly or hydrocephalic children; 
friction of the vertex in women, caused by combs or coiffures; 
friction of the clothing on the wrists or legs; scratching in conse- 
quence of pruritus — all of these induce deterioration and falling of 
the hairs, a condition which may be grouped under the heading of 
traumatic alopecia. 

Pathological Alopecias. — These are much more common. It would 
be logical and may seem easy a priori to subdivide them into two 
groups, according as the fall of the hairs depends upon a local 
affection or is the result of a disturbance of the general health, such 
as an infectious, dyscratic, or cachexia-inducing disease. 

Sometimes the local affection is evident: In this way an eczema 
of the hairy regions, the exfoliative erythrodermas and very exten- 
sive tineas, may lead to diffuse alopecia. I shall not dwell on this 
class of eases, the diagnosis of which is very easy, the treatment 
being that of the causative disease. 

In other cases the hairy scalp appears healthy; here an investi- 
gation will disclose the existence of one of the general diseases which 
will be discussed further on. 

In the vast majority of the cases of diffuse alopecia, however, 
only mild or ordinary lesions are found on the alopecic skin, such 
as pityriasis, seborrhea, etc., which one may hesitate to consider as 
causative. These conditions are interpreted by some writers as 
accessory and irrelevant, by others as the actual cause of the 
alopecia, in my opinion, these various pathological phenomena are 
not interdependent, but are all alike derived from kerosis. 

Kerotic Alopecia and Calvities. — Kerosis is the name which I 
apply to an extremely frequent cutaneous dystrophy, shown by 



ALOPECIAS 409 

combined manifestations such as pityriasis simplex, seborrhea, 
hyperidrosis and nutritional disturbances of the pilary system, in 
the form of hypertrichosis or alopecia. In different cases, one or 
several of these symptoms may predominate. 

It is customary to consider as special pathological types and to 
describe separately, alopecia with seborrhea {alopecia seborrheica) 
with pityriasis {alopecia pityrodes, pellicularis,furfuracea) , and the ap- 
parently essential alopecia {alopecia senilis, prematura and cahities). 

However, these types are very imperfectly defined and can be 
included in one and the same description, a few words sufficing to 
point out the different clinical varieties of kerotic alopecia. 

On the scalp, its seat of predilection, kerotic alopecia is diffuse, 
but regional and progressive. It begins at the vertex, at the place 
of the tonsure and at the sides of the forehead. As it progresses it 
becomes generalized and spreads at an extremely variable rate. 
It may stop half-way or even retrograde slightly in youthful and 
properly treated individuals. Often, however, it progresses inexor- 
ably, denuding the entire top of the head ; it spares for a fairly long 
time a median island at the top of the forehead and almost always 
definitely the temporal and lower occipital regions, so that a semi- 
circle of hairs is left passing from one temple to the other across 
the nape of the neck. 

Before becoming detached, the bulb of the hairs has become solid 
and they will then yield to the slight traction of the brush, etc.; a 
few days later they fall out spontaneously. 

The fall may be continuous, or it may occur paroxysmally in 
variable degrees. Although there are in this respect great individual 
variations or differences according to age, season of the year, mode 
of life, etc., a scalp which regularly loses from thirty to forty hairs 
daily may certainly be said to be in course of denudation and the 
ratio of the daily fall is often much higher. 

The fallen hairs, which at first are healthy and of normal calibre, 
are always replaced; but the successive generations are more and 
more delicate, until they are finally represented merely by a fine 
down, which may disappear in its turn. The resulting condition is 
total baldness {cahities hippocratica) . The skin of the scalp becomes 
white, smooth, glistening, polished, and seems to be atrophied or at 
least slightly thinned. 

In the course of the development of the disease, the scalp has 
almost invariably become affected with the oily scales of pityriasis, 
with seborrhea and hyperidrosis. For a time there may have been 
a production of scaly crusts or more or less circumscribed and figured 
surfaces, accompanied by pruritus; as a matter of fact, eczematides 
are common on the scalp of kerotic individuals and may recur in 
bald persons who neglect personal cleanliness. 



410 TRICBOSMS 

Varieties.- As stated above, the varieties of kerotic alopecia are 

very imperfectly defined. 

According to authors, alopecia seborrheica is said to be precocious 

and rapid in its development, plainly regional and strongly denud- 
ing; alopecia pityr'odes referring to fatty pityriasis, as the dry pity- 
riasis is not depilating (Sabouraud) — is said to be more diffuse and 
always incomplete; alopecia senilis is supposed to depend upon 
cutaneous atrophy and to be unrelated to seborrhea and pityriasis; 
it is slowly progressive and the most relentless in its advance; 
alopecia prematura, often familial, may begin toward the age of 
twenty years and cause baldness at twenty-five or earlier, but has such 
variable features that its pathogenesis is by no means agreed upon. 

In women, notably in young girls and young women, an abundant 
fall of hairs is very common in recurrent, sometimes seasonal periods, 
with more or less fatty pityriasis ; but it only exceptionally leads to 
baldness. The latter is seen in aged women and occupies the temples 
as well as the sinciput. 

Xerotic alopecia of the beard, the moustache, the eyebrows and 
cilia, is much less common and accompanies as a rule fatty pityriasis 
or still more frequently the eczematides of these regions; it is incom- 
plete and always temporary. Bald individuals usually have a fine 
full beard. 

On the trunk, notably on the chest, kerosis produces on the con- 
trary a definite loss of hair in many cases, with persistence of a few 
thick scattered hairs. 

Etiology. — Having previously discussed the etiological factors of 
kerosis, I may here limit myself to stating that mental overexertion, 
night work, a poor dietary hygiene and in fact also a poor hygiene 
of the scalp, dressing the hair brush-fashion, heavy and badly venti- 
lated skull-caps, etc., seem to predispose to progressive alopecia. 

Very frequently the ordinary causes become combined with some 
of the pathological conditions discussed in the next section, con- 
valescence, anemia, dyspepsia, etc., so that the differential diag- 
nosis between kerotic alopecia and alopecia of general diseases is 
often extremely difficult and even impossible in combined cases. 
The prognosis must therefore be guarded. 

| W< >men rarely are bald ; men rarely lose their beards. In fact the 
same conditions affecting the scalp and the bearded region in a man 
may cause a complete alopecia of the scalp while scarcely thinning 
the beard. May we not seek the explanation of the relatively 
greater resistance of the man's beard and the woman's hair in an 
underlying biological fact? The beard of the male and the long 
hair of the female scalp are secondary sex characteristics and as 
such might be expected to possess a greater inherent resistance to 
injury than a useless structure like the hair on the male head.] 



ALOPECIAS 411 

Treatment. — After having corrected, if practicable, all that is 
deficient in the hygiene and health of the patient, the kerosis must 
be treated systematically and for a long time with reducing agents, 
sulphur preparations, tar and mercurial lotions, etc. Later on, 
various stimulating lotions may be prescribed. By these means, 
the trouble is very often successfully checked, or rather the fatal 
outcome may be delayed. 

In established baldness, I have seen a few cases of patients, who 
persisting in very prolonged and energetic treatment, acquired a 
few strong hairs on the denuded surface, but they remain thinly 
scattered and the result is by no means satisfactory from the 
esthetic point of view. 

Alopecias of General Diseases. — A large number of acute infectious 
diseases — typhoid fever, erysipelas, pneumonia, grippe, the eruptive 
fevers, the erythrodermas, etc. — are followed during convalescence 
or after a few weeks' delay by a diffuse acute alopecia. The same 
may result as a sequel of childbirth, severe operations, serious 
traumatisms, violent emotional disturbances. 

The fall of hairs in these cases may be slightly marked or so 
abundant that the hair comes out in handfuls and the denudation 
is practically complete in a few days, constituting the defluvium 
capillitii of the ancients. The alopecia may also involve the hairs 
of the body. The present pandemic of influenza has produced an 
extraordinary number of cases of alopecia. [The defluvium usually 
develops about two months after convalescence.] 

When the scalp is not pityriasic, it is useless to cut the hairs which 
are left; some stimulating washes suffice and the hair grows in again 
as abundantly as before the disease. 

Syphilitic Alopecia. — This condition may be considered to some 
degree as a peculiar instance of this class. It occurs very commonly 
from the third to fifteenth month after the infection. Its onset is 
often insidious. The scalp is not necessarily the seat of eruptions, 
crusts, etc., but there is often a combination with pityriasis. 

There is sometimes a mere thinning of the hair, sometimes a 
regional alopecia [alopecia areolata] which is almost pathognomonic, 
with its incompletely denuded areas oscupying especially the 
temporal regions and the occiput. [The alopecia which is pathog- 
nomonic is what may be described as having a "moth-eaten" 
appearance.] The coexistence of a pigmentary syphilide of the neck 
is not uncommon. 

This syphilitic alopecia must not be confused with pyodermic 
alopecia or with the alopecia areata whose patches even when 
numerous are usually more completely denuded and more sharply 
outlined. Syphilitic alopecia may also affect the hairs of the body, 
the beard, the eyebrows and especially the outer end of the eye- 



412 TRICHOSES 

brows. The hair always grows again, for "syphilis makes no bald 
heads" (A. Fournier). 

hi all the infectious alopecias, a paralysis of the pilary papillae 
is apparently produced under the influence of toxins, comparable 
to that which affects the matrix of the nails under the same con- 
ditions; a very large number of hairs at once assume a solid bulb. 
The condition is therefore a sort of pathological moulting. 

The absorption of thallium salts produces a total alopecia com- 
parable in every way with the infectious alopecias. 

Chronic diseases, anemia, diabetes, cancer, myxedema, exophthal- 
mic goitre, mycosis and the leukemias, utero-ovarian diseases or 
spaying in women, depressing mental diseases, affections of the 
liver and intestines and still more frequently tuberculosis, give rise 
to chronic, diffuse, progressive, alopecias which must be traced to 
their true origin. In leprosy, the hairs of the face in general and 
those of the body fall out, whereas the hairy scalp escapes. 

Circumscribed Alopecias. — The first point to be settled in deal- 
ing with a non-congenital circumscribed alopecia is to decide if it is 
cicatricial or not. 

In a case of cicatricial alopecia, the surface, grain, sheen, color, 
consistence and sometimes the mobility of the skin are modified; 
the hair-follicles have entirely disappeared ; atrophic, brittle, downy 
hairs are never present; when some hairs are left, they are of normal 
calibre. 

Cicatricial alopecia may result from a wound, a burn, a caustic 
agent, or it may follow upon favus, patches of lupus erythematodes 
or scleroderma, ulcerative tertiary syphilides, pseudopelade, acne 
decalvans, etc. The denudation is permanent. The local exami- 
nation and clinical history will clearly indicate the origin. 

A non-cicatricial alopecia is primarily suggestive of alopecia 
areata. In the first place it is necessary to exclude traumatic 
alopecia or a voluntary epilation, as observed in schools and 
barracks, also an existing dermatosis, such as eczema, eczematide, 
impetigo, etc., which are easily recognizable. 

It is noteworthy that impetigo, furuncle and suppurations in 
general, ordinarily have behind non-cicatricial, distinctly outlined, 
round alopecic spots, the size of a dime to that of a silver dollar, on 
which the re-growth of at first downy then normal hairs may be 
delayed for several months. 

These post-impetiginous alopecias, better named pyodermic alope- 
cias-, due to a local blasting of the hairy territory by the toxins of 
the pyococci, are common in children and are often mistaken for 
alopecia areata. They are characterized by the macule which 
may be observed in their center and by the clinical data. A stimu- 
lating lotion suffices for their cure. 



ALOPECIAS 413 

Alopecia areata (la pelade) [area celsi] is the most important of 
the circumscribed alopecia-producing dermatoses. There exists a 
generalized form, known as alopecia decahans [or totalis]. 

Alopecia areata is characterized by smooth, sharply outlined, 
round or oval spots or patches of variable dimensions and number, 
occupying especially the scalp and the beard. These spots appear 
insidiously, as a rule without any particular sensation. Denudation 
of hair is rapid, by tufts, within a few days; it may then slowly 
spread eccentrically, or over a part of the periphery of the 
spot. 

The fall of the hairs follows upon preceding imperceptible changes ; 
they fall out with a solid bulb, many have atrophic roots; further- 
more, broken atrophic, so-called alopecia hairs are found at the 
periphery of the patch, or even at a distance when it is about to 
extend. 

These characteristic alopecia hairs, very abundant in some cases 
(alopecias with fragile hairs, of Besnier), very rare in the beard, are 
from 2 to 6 mm. long, pointed like a [wet] brush at the ends, black 
halfway or in the distal two-thirds, very thin, tapering and decolor- 
ized toward the root, which terminates in a slight swelling; they are 
accordingly club-shaped or like a note of exclamation. Being very 
superficially inserted, they are very easily pulled out with forceps, 
never breaking off. 

Fresh patches are often rose-colored, slightly edematous, riddled 
with dilated pilary orifices containing seborrheic utricles (Sabou- 
raud). After some time, the spot becomes depressed, ivory white, 
entirely smooth, soft to the touch and easily folded. This stage was 
called achromatous alopecia by Bazin. 

A healing patch becomes covered with downy hairs which at first 
are thin, pale and very loosely implanted; these are replaced by 
stronger downy hairs and finally by normal hairs, actually thicker 
and darker than the original, but sometimes on the contrary white. 
The new growth may be central and centrifugal, or it may be 
centripetal. 

The areas of alopecia, very variable in number, are situated at 
any point of the scalp, perhaps more frequently near the vertex, 
on the parietal and the occiput; anywhere in the beard, especially 
on the sides of. the chin; more rarely on the eyebrows and lids, as 
well as on other hairy regions of the body. A symmetrical tendency 
has been noted in some cases and on the other hand a regional dis- 
tribution in others. 

As varieties may be described : a form with multiple small spots, 
resembling syphilitic alopecia; a form with a large patch extending 
like a crown from the nape of the neck, above the temples and to 
the forehead; this is the ophiasis of Celsus or alopecia coronarius 



I I I TRIC HOSES 

peculiar to children, according to Sabouraud; it is especially obsti- 
nate as are all the alopecias which affect the border of the scalp. 

Alopecia decahans is the most serious variety. It begins like the 
ordinary form often in very extensive areas which remain limited 
for several days or even several months. Suddenly, in a few days, 
the alopecia then becomes generalized over the entire or nearly the 
entire scalp, face and body, sometimes leaving a tiny tuft or a few 
islands of hair. In this last named form are sometimes seen a 
relaxation of the skin permitting it to be easily folded, i. e., hypo- 
tonia; and lesions of the nails, which will be discussed elsewhere. 
Slight sensory disturbances have been noted on the smooth surfaces, 
cryesthesia, hypoesthesias, etc. 

The course of alopecia areata is very variable. Mild cases are 
cured in two to six months. Recurrences, appearance of new 
patches before the first have healed and relapses at any time are 
extremely common. There occur cases of incessant renewal and 
fall. Alopecia decahans lasts from one to four years and is entirely 
cured in youthful individuals, incompletely in older patients. 

Etiology and Nature. — Twenty years ago, alopecia areata was 
almost universally believed to be parasitic and contagious; at least 
a contagious form was admitted. The stories of epidemics in schools 
and barracks, quoted in support of this contention, were scattered 
and blown away like smoke as soon as it could be recognized by 
careful investigation that there was always a coincidence of sporadic 
cases with cicatrices and various pseudo-alopecias or with ring- 
worm. Credit is due to Lucien Jacquet for his indefatigable work 
in proving the non-contagiosity of pelade; his thousands of experi- 
mental inoculations on himself and on already affected, therefore 
predisposed, subjects, did not yield a single positive result. 

In favor of a nervous origin of alopecia areata have been quoted 
the experiments of Max Joseph who through division of the occipital 
nerves in cats produced bald spots which, as a matter of fact, had 
only an apparent analogy with alopecia areata; and on the other 
hand, the not uncommon coincidence of alopecia areata with 
neuralgias, headaches and an "unbalanced" nervous state. 

In the dystrophic theory of Jacquet, the predisposing role was 
attributed either to a complex organic deterioration, as indicated 
by urinary analysis, or to hereditary factors. On the soil thus 
prepared, the alopecia was assumed to be elicited and focussed 
through local peripheral, or visceral, or central irritations. Among 
the irritations starting the reflex, those of dental origin are the most 
common; very often the eruption of the teeth, more particularly 
the wisdom teeth, or dental caries, alveolar inflammations, badly 
fitting dentures and so forth can be held responsible. There is 
even a certain relation between the localization of the bald areas 
and that of the irritative focus. 



ALOPECIAS 415 

Taking up the question ab ovo, Sabouraud and his school started 
of recent years a new inquiry concerning the etiology of pelade. It 
appears that this affection is hereditary or familial in at least 22 
per cent, of the cases; the affection is only half as frequent in the 
female as in the male sex; its maximal frequency of onset is, in both 
sexes, between the age of six and twelve years; it is furthermore 
observed with relative frequency in women at the time of the 
menopause or after a prolonged suppression of menstruation, 
through spaying, for example, and more rarely in the course of 
pregnancy. 

Statistics finally show a connection between alopecia areata and 
thyroid disturbances, especially exophthalmic goitre, where it is 
apt to be chronic and severe. As to the etiological relations with 
acquired or congenital syphilis, these are neither clear nor direct; 
syphilis could be demonstrated in only about 10 per cent, of the 
cases of alopecia areata. 

These data are undoubtedly interesting, but on the whole it 
must be admitted that the real nature of alopecia areata still 
remains unknown. 

Treatment. — Since it is known that alopecia areata is never and in 
no degree contagious, the prophylaxis of this affection has assumed 
an altogether different direction. There is now no reason to isolate 
the patients or to keep them away from gatherings, schools, work- 
shops, barracks, etc., to refuse them a clean bill of health, nor to 
suspect hairdressers or barbers, caps, hats, pillows, etc., of having 
transmitted a disease which is non- transmissible. 

The treatment of alopecia areata and the prophylaxis of relapses 
or recurrences, are therefore purely individual. 

An effort must be made in a given case to determine the existing 
factors of nervous and trophic loss of balance, in order to treat its 
general and deep causes. In the presence of overstrain, bad hygienic 
conditions, organic or functional disturbances, it may be necessary 
to recommend relative rest, life in the open air, in the country or the 
mountains; dry or alcoholic friction of the entire body; hydro- 
therapy in its tonic or sedative forms, or perhaps various opothera- 
peutic measures, or the reconstructives, phosphates, arsenic, etc. 

On the other hand it is very important to look for the localizing 
causes, as it were. A bad condition of the teeth and gums requires 
attention, even in the absence of pain, congestion, neuralgia, etc. 
This point must be emphasized ; I have personally seen, like Jacquet, 
a considerable number of cases which had resisted all local medica- 
tion heal of their own accord with suggestive rapidity after expert 
treatment at the hands of a dentist. Sometimes the "peladogenic" 
focus is to be found in the ears, nose or pharynx and one must 
proceed accordingly. 



416 TRICHOSES 

The local measure* may he summarized as follows: repeated, 
sufficiently energetic but not exaggerated stimulation of the denuded 
areas. This stimulation may be mechanical, being obtained by 
massage, petrissage, brushing, twice daily or oftener; in the stage 
of re-growth, it must be remembered that of all stimulants epilation 
acts the most directly upon the pilary papillae. Chemical stimu- 
lation may be accomplished by means of iodized, acetic or ammoni- 
acal, chloroform or alcoholic, or other mixtures selected from the list 
of stimulating and rubefacient lotions; the applications should be 
made every day or at longer intervals. [Pure liquified phenol 
allowed to act till the surface begins to whiten, then de-ionized by 
means of alcohol, applied once in two or three weeks, is an excellent 
local stimulant.] Vesication or blistering, more particularly by 
means of a liquid vesicant painted on with a brush, may serve to 
whip up the pilary growths, as it were. Physical stimulants may 
also be employed, such as faradization, high frequency currents, etc. 
I have witnessed in my laboratory, in cases of alopecia decalvans, a 
remarkable re-growth under the influence of radiotherapy, strictly 
limited to the stimulated regions; of course the .r-rays must be 
employed in lower dosages than those which cause epilation (2 to 3 
units H every fifteen or twenty days). Numerous authors have 
recently recommended the employment of ultra-violet rays. 

Salves and plasters which are sometimes given to these patients 
possess no special virtues. 

The condition of the scalp should be attended to as a whole, treat- 
ing pityriasis, seborrhea, or concomitant lesions if present. 

In order to facilitate the local treatment in cases with extensive 
or numerous areas, it is advisable to cut off or shave the remaining 
hair.- In this case a wig will have to be worn, if the patient desires 
to conceal his condition. When the patches are not very extensive, 
they can be hidden more or less effectually by touching them up 
with burned cork. 

DYSTROPHIC TRICHOSES. 

Leukotrichia and Canities. — Congenital absence of pigment in 
the hairs is known as leukotrichia. It is generalized and accom- 
panied by a lanugo-like atrophy in albinism, which is very rare, or 
it may be partial, limited to a tuft of hair, as occurs hereditarily in 
certain families. 

Canities is an acquired achromia; the hairs on the scalp and body 
turn grayish, then gray and finally entirely white. It is 'physiological 
aficr a certain age, but very variable according to races, families, 
individuals and mode of life; so that in a given case it can be desig- 
nated as senile or as premature. Its distribution and relative develop- 
ment on the scalp, the beard and the other hairy regions are so vari- 



DYSTROPHIC TRW HOSES 417 

able that no summary account is possible and all that can be said is 
that the condition is essentially diffuse and progressive. 

Pathological canities, more or less extensive and diffuse, is seen in 
the course of several nervous diseases and of cachexia. 

Numerous cases have been quoted in which canities is said to 
have developed suddenly, in a single night, for instance, under the 
influence of extreme terror; Dr. Parry is said to have seen the hairs 
of a sepoy who had been tied to the muzzle of a cannon whiten in 
half an hour. This is highly improbable. I do not know of any 
observation on sudden canities in the course of the last four years, 
which have certainly been prolific of unspeakable horrors. 

Sometimes, a partial canities which may be temporary, follows 
after baldness due to alopecia areata, erysipelas, and so forth. 

The mechanism of the decoloration is unknown. The hairs very 
rarely whiten, gradually beginning at the root or at the free end. 
Cases of ringed canities [pili annulati] have been reported, with 
alternately white and colored segments. As a rule, the blanching 
is total, progressive and more or less rapid for a given hair. 

The penetration of air between the cells of the hairs does not 
sufficiently explain the whiteness; there is not only failure of pro- 
duction but actual destruction of the pigment, either through special 
pigmentophagous phagocytes, as claimed by Metchnikoff, or more 
probably through consumption of the pigment in situ. 

The treatment of canities is practically illusory. The role of 
internal medication and hygiene is limited to raising the general 
nutritional standard. Stimulating applications, heating the scalp 
according to some, or epilation of the first white hairs may at the 
onset delay the appearance of canities. 

Actually, the only corrective agent which certain individuals are 
obliged to employ for business reasons, consists in the use of hair- 
dyes. With the exception of burned cork, or henna which gives a 
red or blond color or a brownish tint, according to its mode of 
application and hydrogen peroxide which reddens and bleaches the 
still pigmented hairs, all dyes may be injurious; several are positively 
dangerous, more particularly those containing paraphenylendiamin. 
The least harmful are perhaps the silver nitrate and pyrogallic acid 
preparations. Numerous formulas may be found in special works 
on this subject. 

Trichorrhexis Nodosa. — Under this name is designated a very 
common affection of the beard in men and of the scalp and pubic 
hairs in women, characterized by a localized splitting of the hair, 
the fibers becoming separated in the form of two brooms pushed 
into each other. 

This results in the appearance of white nodosities, at the level of 
which the hair bends and is easily broken off. These thickenings are 
27 



418 



TRICHOSES 



numerous, especially toward the free end and lead to shortening of 
the scalp or body hairs. 

This affection was considered for a long time as parasitic and 
contagious. Sabouraud, who found it in nearly all the old shaving 
brushes examined by him, showed it to be traumatic and due to an 
excessive withdrawal of oil through abuse of soapy washes and 
lotions. The remedy is therefore to cut the hairs below the fractures 
and to keep them constantly oiled. 

Trichoptilosis. — Trichoptilosis is a cleavage in the longitudinal 
direction of the hairs on the scalp or of long beard-hairs, which 
become forked at their extremity. Severe chronic diseases or con- 
stitutional weakness may perhaps act as predisposing factors 
although it is also observed in perfectly healthy individuals. The 
disease seems to depend upon an exaggerated dryness of the hair. 
The treatment is that of trichorrhexis. 




Fig. 130. — Monilethrix, showing the scalp and the parotid and palpebral regions in a 
child aged nine years. 



Monilethrix or Aplasia Moniliformis. This is a rare, familial 
and hereditary congenital dystrophy, related to keratosis pilaris and 
ichthyosis (Fig. L30). 

It consists of a peculiar conformation of the hairs which are alter- 
nately and regularly constricted and swollen, spindle-shaped, dry, 
shrivelled, brittle and usually very short: the fractures occur at the 



PARASITIC TRIC HOSES 



419 



level of the constrictions; the thicker portions are more pigmented 
(Fig. 131). 

One is inclined to admit that the formative hair-papilla under- 
goes changes of dilatation and atrophy, comparable to a pluri- 
diurnal rhythmic pulsation. The follicles usually present the lesions 
of keratosis pilaris and often form an acuminate elevation which 
may ultimately become replaced by a minute cicatrix. The scalp 
is especially affected and generally appears entirely denuded. 
Hallopeau showed that the pilary system of the entire body may 
be involved. Sometimes this dystrophy slightly subsides with 
advancing age. 

The treatment is that of keratosis pilaris. 




Fig. 131.— Monilethrix. 



PARASITIC TRICHOSES. 

There are two kinds of parasitic diseases of the scalp- and body- 
hairs: (1) the tineas, in which the parasites reach the hair at its root 
and invade the follicle as well as the surface-epidermis; (2) the 
trichomycosis, in which only the shaft of the hairs is affected. 

Tineas. — The name of tineas must be reserved at the present 
day for a group of parasitic dermatoses of the hairy scalp due to 
fungi. They are extremely interesting not only for dermatologists 



420 TRICHOSES 

but for all physicians, representing very insidious diseases, some- 
times hard to recognize, of proverbial tenacity, difficult to treat 
and, moreover, highly contagious. They have, accordingly, a social 
importance. 

The tineas are three in number: Tinea favosa (favus), tinea 
microsporica and tinea trichophytica. The last two may be com- 
bined under the name of tinea tonsurans. The general discussion of 
their parasites will be found in the chapter on parasitic dermatoses 
(Chapter XXV). 

Children alone are liable to contract tineas, the reason for this 
privilege being unknown; it must be assumed that in them the 
chemical constitution of the scalp differs from what it will be after 
puberty. Aside from the matter of age, there exist no conditions 
of immunity. All tineas result from contagion, either direct by 
contact or more generally indirect by mediation of toilet articles, 
combs, brushes, clippers, scissors, towels, hats, etc. Transmission 
between children of the same family is extremely common. Real 
epidemics may be observed in schools or gatherings of children 
where an unrecognized tinea-carrier has been admitted. 

With these remarks on the general etiology, each tinea will now 
be discussed separately. 

Tinea Favosa [Favus]. — The hairy scalp is the seat of predilection 
of favus. At the onset, the achorion vegetates on the surface, only 
in the horny layer, where it causes red and scaly spots; this stage 
usually passes undetected. 

In the fully developed stage, the most typical clinical form is that 
known as favus scutularis, the "favus a godets" (favus with cups); 
it is described as favus urceolaris when the scutula are discrete, 
regular, centered by a hair and of a bright sulphur-yellow color; 
favus squarrosus, when they are confluent, misshapen and con- 
glomerated in grayish, powdery, scaly crusts held together by 
dried pus. 

The spots or patches of favus are of very variable extent, some- 
times larger than the palm of the hand. The entire scalp may be 
invaded except a border about 1 cm. in width which curiously 
enough always remains free. 

On removing the cups (p. 51G) with a curette, there is found below 
either a smooth depression or a suppurating ulcer or at any rate a 
subacute dermic inflammation with a tendency to cicatrization. In 
long-standing patches of favus, cups and crusts are accordingly seen 
intermingled with smooth, pinkish cicatrices of irregular shape. 

On the favus patches the hairs have in part disappeared; those 
which persist emerge in tufts from the interstices of the crusts. They 
are dull, discolored, resembling tow. They do not break easily but 
yield readily to traction, with their root surrounded by its swollen, 



PARASITIC TRICHOSES 42] 

inoist, white or hyaline epithelial sheath. The microscope readily 
reveals the mycelium in the hairs at least in the first portion of their 
length. 

The hairs which have fallen out are not replaced. Favus of the 
scalp leads more or less rapidly to cicatricial alopecia, arranged in 
spots or networks, characterized by its smooth, shining, more or less 
reddened and sharply outlined surface; here and there, crinkled 
hairs of normal thickness and length persist isolated or in small 
groups. 

In other cases the cups are not apparent and it is the dull and 
grayish appearance of the hairs emerging from the affected regions 
which indicates the condition present. 

The pityriasic form of favus manifests itself as distinctly outlined 
spots, covered with dry gray scales; the microscopic examination of 
the scanty and lustreless hairs establishes the differential diagnosis 
from psoriasis or eczema. 

In the impetiginous form of favus, crusts especially are seen, 
gluing the hairs together and affording a lodging for pediculi. There 
is always a history of the lesion dating back several years. 

Removal of the crusts exposes a pinkish bald surface ; after some 
time, scutula appear, pierced by lustreless hairs infiltrated with 
mycelium. 

The alopecic form very closely suggests pseudo-favic alopecia. 
There are no crusts or scales, but spots or islands of cicatricial 
alopecia; at their circumference are seen slightly papular folli- 
culitides; a microscopic examination of the emerging hairs is neces- 
sary to establish the differential diagnosis from acne decalvans. 

Tinea Microsporica. — Tinea tonsurans with small spores — or tinea 
of Gruby-Sabouraud — is frequent in children from four to ten 
years, especially in boys; it is extremely contagious. When left 
untreated, it disappears spontaneously at about the age of fifteen 
years. 

It may be recognized from a distance as round or oval, large or 
medium-sized, distinctly outlined patches of a dusty appearance, 
covered with gray foliated scales, whence emerge only a few healthy 
hairs nearly all being broken off short, of a length of about 3 to 5 
mm., lustreless and of an ashen gray color, all inclined in the same 
direction (Fig. 132). 

It is seldom that only a single patch is present; generally from 
four to ten can be counted. 

The most recent patches are lenticular or nummular in size; the 
oldest may measure 5 to 6 cm. in diameter or more. The condition 
has therefore been described as having large patches but small 
spores. Diseased hairs scattered outside of the patches can never 
be demonstrated. But the hairy scalp may be involved as a whole. 



!_'•_' 



TRICHOSES 



( )n grasping the hairs of a patch of microsporia tinea between the 
nails of the thumb and index finger, or between the blades of a pair 
of forceps, a certain number can be easily pulled out without pain, 
for they break oil' a short distance below the epidermic surface. 

Viewed with a lens these hairs are seen to be surrounded by a 
dull white sheath for a distance of 1 or ."» nun. Microscopical 
examination, after the action of 40 per cent, caustic potash solu- 
tion, shows this sheath to be formed by a thick and regular layer of 
round or polyhedral, somewhat uneven spores, measuring from 




132. — Tinea tonsurans m 



jrosporica. The cultures yielded niicrosporon 
lanosum. 



2 to 4 ji in diameter; the hair thus resembles a rod dipped in glue 
and then rolled in fine sand. The spores do not generally seem 
to be accompanied by mycelic threads, are not arranged in short 
chains and are evidently ectothrix [outside the hair-shaft] (Fig. L33). 

Careful inspection of the hair after it has been freed from its 
sheath of niosaie-likc spores, may nevertheless reveal delicate 
mycelic filaments, with widely separated septa, dividing from above 
downward dichotonously, with superficially emerging brandies, 
which perhaps give rise to the spores. At the lower portion of the 
microsporic hair broken off near its bulb, numerous mycelic threads 
can sometimes be seen, constituting what is known as "Adamson's 
fringe." 

The presence of friable hairs clinically differentiates the small- 



PARASITIC TRICHOSES 



423 




Fig. 133.— Radicular portion of a hair in tinea microsporica (microsporon lanosum.) 
B and C, microsporon sheath; at A the subjacent threads of mycelium are shown; 
D, mycelic fringe of Adamson; E, epidermic cells of the cuticle or of the follicle. After 
Sabouraud. X 260. 



424 TRICHOSES 

spored tinea tonsurans from pityriasis capitis, which moreover is 
generally diffuse; from psoriasis of the seal]) and from the form of 
dry eczema named tinea amiantacea by Alibert. In these various 
affections, on the contrary, the length of the hairs is preserved, they 
are solid and fall out as a whole without breaking. The differences 
between the small-spored tinea tonsurans and trichophytosis of the 
hairy seal]) will appear from the following: 

Tinea Trichophytic a. — Trichophytic tinea tonsurans — or tinea 
with large spores — likewise affects children exclusively; but it may 
be prolonged until about the twentieth year or exceptionally 
later. It is actually twice as common in Paris as the small-spored 
tinea, especially among girls. In contradistinction to the latter, it 
manifests itself as small patches, scattered in large numbers, or 
rather as numerous dots, each made up of a few diseased hairs; 
these dots become fused and may form larger patches, of any shape, 
but a large number of healthy hairs which hide the diseased hairs 
usually persist. This tinea has therefore much less striking symp- 
toms and may escape an inexperienced observer. 

A distinction must be made between two principal varieties, two 
clinical types, depending upon different trichophytic species. Their 
distinctive features are as follows, according to the description of 
Sabouraud : 

1. The diseased hairs, intermingled with numerous healthy long 
hairs, may be gray, broken off at a height of 2 to 4 mm., bent in all 
directions, bristling as it were; the epidermic surface is covered w T ith 
dry or greasy, rather thick scales, containing twisted infected hairs ; 
this form constitutes trichophyton with crateriform growth [in cultures; 
briefly T. erateriforme]. 

2. In the other variety, the diseased patches between the surviving 
hairs are dotted with black points resembling powder grains and 
sometimes with follicular elevations analogous to those of keratosis 
pilaris; no diseased hairs protrude; they are enclosed in the horny 
layer, broken off flush with the surface or twisted on themselves in 
the follicular ostium. These are cases of trichophyton with acuminate 
growth [T. acuminatum]. 

The hairs for microscopic examination must not be taken hap- 
hazard or pulled out with the fingers, for the tinea w r ould then 
remain unrecognized. Remnants of hairs must be looked for and 
extracted with fine pincers or with a needle. These diseased hairs 
will be found to be packed with spores larger than those of micro- 
sporon and lodged in the substance of the hair itself; these tricho- 
phytons therefore are endothrix (Fig. 134). 

If the spores are square, lie in tiers or bands with resistant [co- 
herent] mycelium, the case is one of trichophyton erateriforme. If 
the spores are rounded or oval, easily separated, the myecelium 



PARASITIC TRICHOSES 



425 



brittle and the hair resembles a bag of nuts, the case is one of 
trichophyton acuminatum. 

According to the investigations of Sabouraud (1908), this micro- 
scopical difference is not absolute, however, and cultures are required 
for the differentiation of the two species. 

Tinea trichophytica is more often overlooked than confused with 
other affections. Not infrequently it is a patch of herpes circinatvs 
occurring [on the glabrous surface] on the little patient or some one 
in his invironment that first attracts attention; or there may be a 
diffuse alopecia accompanied by a slight scaling on the scalp. 




Fig. 134. — Hair in trichophytic tinea, trichophyton crateriformis. Threads composed 
of quadrangular segments forming bands of mycelium. After Sabouraud. X 260. 



Every pityriasis with multiple spots and all dry eczemas localized 
on the scalp of children, require a minute and painstaking search 
for hairs broken off or enclosed in the epidermis and such will very 
often be found provided one knows how to look for them. 

It is superfluous to emphasize that the broken hairs of alopecia 
areata which are dry, clubbed, thinned at their base and can be 
extracted without breaking, in no way resemble the hairs in tinea. 



426 TRICHOSES 

Treatment of the Tineas. — No general treatment is required, but 
these patients recover more promptly when their general condition 
is improved and when they are placed under excellent hygienic 
conditions, in the country, at the seaside, etc. 

The prophylaxis necessitates immediate strict isolation of the 
patient, especially from other children. 

Favus-carriers are dangerous for everybody; children suffering 
from the microsporic and trichophytic forms can transmit to adults 
only a readily curable herpes circinatns. All tinea patients, even 
when collected in a special school reserved for them, like the school 
of the St. Louis Hospital in Paris, must keep the head constantly 
covered and be regularly cared for. 

In treating a case of tinea, it is indispensable to begin by cutting 
the hair short with scissors, repeating this every eight or ten days. 
The next indications are to outline all the diseased points, to remove 
or destroy the parasites by appropriate measures and to preserve 
the healthy portions. 

In a case of tinea tonsurans, after the scalp has been washed with 
soap, it is advantageous to paint it all over with tincture of iodin 
diluted with three parts of alcohol; this serves to bring out the 
affected regions and protects the healthy parts from auto-infection. 
These soapy washes and iodin applications may be repeated every 
day or every other day. 

Where a radiotherapeutic apparatus is available, epilation by the 
.r-rays which evacuates the entire contents of the follicles is the 
method of choice. As shown by Sabouraud, tineas are curable in a 
relatively short time by this method — from four to six months, for 
example, instead of two or three years consumed in the old methods. 
All the spots are successively exposed to the rays, administering the 
necessary doses, namely 5 units H. in one session. When the spots 
are very numerous and scattered, it is necessary to treat the entire 
seal]), which requires twelve applications, in one or two days. Great 
care must be taken in outlining the exposed territories, so that no 
strip of skin either escapes or receives a double dose. The employ- 
ment of the method therefore requires a perfect apparatus, wide 
experience and great care. Between the fifteenth and twentieth day, 
all the hairs together w r ith their roots are cast off; by the thirtieth 
day, neither hairs nor parasites are left and the child is no longer 
contagious. The re-growth of hair begins at the end of two and a 
half months and is complete five months after the session; it goes 
without saying that during this period the children must be care- 
fully watched. [It is advisable to paint the scalp with the dilute 
tincture of iodin once a week for several weeks after the raying.] 

When radiotherapy is not available, a strip 8 mm. in width 
must be epilated with forceps around each patch, in order to estab- 



PARASITIC TR1CH0SES 427 

lish a safety zone; and then, as well as possible, the patches them- 
selves, where the hairs are unfortunately brittle; these epilations 
to be repeated every ten or fifteen days. Furthermore the spots 
should be painted every day with iodin tincture diluted to one-fourth 
strength; they should be dressed with iodized vaselin or with a 
chrysarobin salve; occlusion should be maintained by means of 
zinc gelatin or strips of adhesive plaster. It has also been recom- 
mended to rub the spots every fifteen days with a pencil of croton 
oil contained in cocoa-butter. The last named topical agent gives 
rise to folliculitis with expulsion of the infected hairs, but is liable 
to leave cicatrices; its action must be closely watched and the 
inflammation quieted with moist dressings. The treatment is con- 
tinued in this way until a cure seems to have been accomplished. 

Without radiotherapy, a properly treated small-spore tinea 
tonsurans lasts about eighteen months; many cases are prolonged 
for two or four years. This tinea finally always gets well without 
cicatrices, unless these have been caused by the treatment. 

The prognosis of trichophytic tinea is aggravated by the multi- 
plicity of the affected points and the difficulty of discovering them ; 
moreover, it does not disappear spontaneously until the age of 
eighteen to twenty years. By means of correct treatment, a cure 
can be obtained in less than one year. It often happens, especially 
in the trichophytoses, that two or three follicles resist almost indefi- 
nitely; one is justified in destroying these by electrolysis, by the 
thermocautery, or by the application of a small droplet of croton 
oil, introduced with a needle. Many microscopical examinations, 
repeated every month and yielding negative results, are necessary 
before the case can be pronouncd cured. 

In tinea favosa the treatment begins with the removal of the 
crusts and cups by means of moist dressings, salicylated vaselin, 
or the wearing of a rubber cap, together with frequent shampooing. 
When the scalp is clean, epilation is performed either by means of 
the ar-rays or with forceps, which is more efficient in these cases; 
this is repeated every month. In the interval, the parts are painted 
daily with dilute iodin tincture or carbolized glycerin. Various 
ointments of sulphur, copper sulphate, mercurial salts, etc., have 
also been recommended, but are of no advantage. 

The treatment of favus by epilation, formulated by Bazin, requires 
at least six or eight months, sometimes over a year. A cure can be 
considered as probable only after no cup and no infected hair has 
reappeared for three months after the last epilation. As a recur- 
rence is even then not excluded, it is necessary to watch the patient 
during at least another six months. 



I-JS 



TRICHOSKS 



TRICHOMYCOSES. 

These are parasitical affections of the hairs, affecting their free 
shaft, hut not the root or the follicle. Several varieties are known: 

Trichomycosis Vulgaris (Lepothrix of Wilson, or Trichomycosis 
PalmeUina (Pick) is common in all countries, in the axillary and 
genital regions, in persons who neglect the demands of cleanliness. 
The hairs become dull, roughened, nodular, assume a yellowish or 
reddish color, but are not brittle; there is often a regional hyper- 
idrosis and ehromidrosis. 




Fig. 135. — Trichomycosis vulgaris; axillary hairs under the microscope. 



Under the microscope, very adherent granular concretions are 
seen on the hairs, forming an irregular sheath, a sort of rugous 
cortex (Fig. 135) or nodules at intervals. They consist of zooglea 
of cocci, attached to erosions of the cuticle of the hairs and agglom- 
erated in a very hard layer. Colombini successfully cultivated and 
inoculated this parasite. 

There exist tropical varieties, such as that studied in Ceylon by 
Castellani (1912), due to Nocardia tenuis. 

Washing with soap and antiseptic lotions or ointments suffices for 
the treatment; shaving of the hairs is only exceptionally required. 

Piedra ( Trichosporosis Nodularis Tropicalis) gives rise to nodes 
in the hairs, sometimes of the beard, arranged without order and 
conveying a sensation of roughness on touch. The rounded or 
spindle-shaped nodules, sometimes of the form of a unilateral shell, 



PARASITIC TRICHOSES 



429 



are whitish, extremely hard and adherent (Fig. 136); they do not 
make the hairs brittle; Juhel-Renoy counted 23 on a single hair 
60 cm. in length. 




Fig. 136.- — Piedra nodules completely or partially surrounding the hair. 

They are composed of fairly large spores, belonging to one or 
various species of trichosporum, heaped up and agglutinated under 
the cuticle of the hair. This affection is observed in South America, 
especially in Colombia, in the Balkan Peninsula and exceptionally 
in temperate climates. 



CHAPTER XXI. 
ONYCHOSES. 

The nail is a horny plate resulting from a special type of kera- 
tinization. This particular mode of keratinization is limited in man 
to the floor of a deep depression in the epidermis of the dorsal 
aspect of the terminal phalanges. 

The ungual plate or nail-plate is of convex shape, especially in the 
transverse direction and its root is inserted into this depression, 
which has the form of a groove or notch. The root is bevelled on its 
lower surface, the bevelled edge corresponding to that portion of 
the invaginated epidermis which secretes the nail and which is 
known as the matrix of the nail (Fig. 137). 




Fig. 137. — Nail of the index finger of a newborn infant; longitudinal section. 
The middle third of the section has been omitted from the drawing. A, root; B, supra- 
ungual fold; C, nail; D, subungual groove; E, free border; F, matrix; G, bed. X 13. 



The nail-plate formed in the matrix grows in the direction of the 
extremity of the finger or the toe. When it has pushed forward 
from under the supra-ungtial [posterior] fold, the body of the nail 
rests on the bed of the nail and its borders are insinuated under the 
lateral (olds. Its extremity is free and passes above the subungual 
groove. 

The growth of the nail, which is about 3 nun. monthly, therefore 
depends upon the activity of the ungual matrix. Any lesion of this 
matrix as a whole will manifest itself in an arrest of growth and may 
be finally marked by a transverse ridge on the ungual plate when this 
lesion has been temporary; by an atrophy of the nail when it is 



CONGENITAL MALFORMATIONS 431 

permanent. The partial lesions of the matrix will result in a spot 
when they are temporary, a streak or a longitudinal band when they 
are persistent. The thickness of the nail seems to depend upon the 
degree of slanting of the matrix. 

The bed of the nail enters to only a very slight extent into the 
formation of the nail which is not thicker at its free extremity than 
at its root. Nevertheless pathological changes of the nail-bed play 
a certain role in the onychoses. 

The diseases of the nails, known as onychias or onychoses, therefore 
depend on pathological changes of the ungual matrix and to a small 
extent on those of the nail-bed; their inflammatory forms are 
designated as onyxis. 

It is customary to describe with these onyxis the perionyxis, 
namely inflammations of the supra-ungual and lateral folds which 
are clinically hardly separable. 

In a general way, the onychoses are very common. They may 
depend on (1) Congenital malformations; (2) local causes, various 
traumatisms or parasitic affections (onychomycoses); (3) a locali- 
zation of various dermatoses; (4) the effect of a general disease; (5) 
trophoneuroses . 

These very different causes and perhaps also still others of 
unknown nature, give rise to equally variable lesions. It must be 
emphasized, however, that no absolute conformity exists between 
a given cause and its apparent effect upon the nail; identical or 
related causes may produce very different symptomatic pictures, 
while on the contrary the same appearance may result from a 
variety of causes. 

On account of the difficulty of biopsies and the rarity of post- 
mortem examinations, the pathological anatomy of the onychoses is 
very imperfectly understood. 

The diagnosis of the onychoses is very often difficult and may 
remain open, unless the lesion is a rare and characteristic one, or the 
nature of the affection is elucidated by the presence of other cuta- 
neous localizations. In spite of the remarkable work of Heller and 
numerous special contributions, this subject still remains somewhat 
obscure. 

Congenital Malformations. — These may consist, on both extremi- 
ties, in the complete absence of one or several nails {anonychia), 
sometimes the nails are replaced by a horny mass {epidermic nail) ; 
or they may be found to be atrophic, thin, concave, shovel-shaped 
{koilonychia) ; or they may be hypertrophied {scler onychia) , thick, 
blackish, roughened, curved transversely, claw-like {onychogry- 
phosis), or flakey or longitudinally striated, or wavy, etc. These 
malformations are not uncommonly familial, transmitted through 
several generations, sometimes associated with malformations of the 



432 



ONYt HOSES 



fingers, dystrophies of the hairs or other hereditary errors of con- 
formation, as well as with various keratoses. It must be kept in 
mind that malformations of hereditary origin like the nevi some- 
times do Dot appear until advanced childhood or still later. 

Traumatic Onychoses. — Wounds, ecchymoses, avulsions of the 
nails, subungual foreign bodies, traumatic onyxis and perionyxis, 
ingrown nail, etc., belong to the domain of surgery. 

Onychophagia, a bad and sometimes unconscious habit of gnawing 
the nails, is usually connected with other stigmata of degeneration 
or with nervous disturbances. It is observed in children of both 
sexes and even in adults. It is partly referable to heredity, but 
also largely to imitation; in some schools, more than one-third of 
the children bite their nails. 



- 





Fig. 13S. — Finger nails worn down by scratching. From a case of prurigo vulgaris 
with eczematization. 



The gnawed nails no longer have a free border; in the extreme 
degree, they are reduced to transverse stumps, the pulp of the 
fingers rising up as a cushion in front. This unclean habit may 
become dangerous through the absorption of pathogenic germs 
which have lodged under the nails. Compulsory measures and 
physical agents are rarely efficient; psychotherapeutic treatment is 
preferable. 

Worn-off nails, combined or not with various artificial colorations, 
arc encountered in a large number of manual occupations. 

In chronic pruritus and the prurigos, the free border of the nails 
may become concave and worn, their surface being as smooth as a 
mirror (Fig. 138); this appearance indicates habitual scratching 
to the dermatologist, even when the patient is unaware of the habit 
or wishes to conceal it. 

The popular name of hang nails is applied to small traumatic 



ONYCHOMYCOSES 433 

tears or epidermal elevations of the posterior fold and the lateral 
folds; they easily become the source of infections, lymphangitis, 
etc., and should be carefully trimmed [sterilized with iodin] and 
covered with collodion. 

Onychomycoses. — The ungual lesions produced by the achorion 
and the trichophytons (Chapter XXV) differ only by mere shades. 
The diagnosis is based upon the possible coincidence of other locali- 
zations of favus or trichophytosis, and especially on the microscopical 
examination. 

Onychomycosis favosa is rare and, as a rule, secondary to favus 
of the scalp or body which may, however, have healed while the 
ungual lesion still persists. It begins in the subungual grooves or 
at the lateral borders, as straw-colored yellow spots which are seen 
shimmering through the nail-plate; these spots grow, raise the nail, 
which finally becomes cloudy, thickened, fissured, locally puffed up, 
loosened and exfoliates. At last nothing is left of it but roughened 
and striated debris. The growth of the achorion under the nail 
gives rise to a horny substance (Truffi); the nail plate itself is 
invaded secondarily; but according to Pellizari, it may be attacked 
primarily. As a rule, the majority of the finger-nails are involved; 
very exceptionally the toe-nails. 

The onychomycosis trichophytica is generally caused by trichoph- 
ytons of animal origin. It is more frequent in adults than in 
children and often coincides with trichophytosis of the beard or of 
the hairless skin. Several nails are generally involved, without 
regard to order. The. lesions begin under the free border or under 
the lateral borders of the nail, as grayish spots with irregular or 
vague borders, not so yellow as in favus. A beginning at the root 
also is said to have been noted. When the nail itself is invaded, its 
external table may be preserved or not; in the former case, the 
nail is greatly thickened, opaque, striated like rush-pith, friable at 
its free border, concave, or on the contrary curved in and claw- 
shaped; in other cases the external table is fissured and worn and 
the nail eroded, spongy, roughened, dirty and more or less de- 
stroyed. 

The onychomycoses are painless. They may undergo a spon- 
taneous cure, but when left untreated usually last a very long time, 
up to twenty years or more; they are, moreover, very rebellious to 
treatment. 

In a general way, oxychomycoses should be suspected in the 
presence of any chronic onychosis of obscure, supposedly trophic 
cause, etc. 

Microscopical examination of nail-dust, scraped off and heated 
on a glass slide in a 40 per cent, potash solution, shows mycelic 
elements, which are shorter and more irregular in favus than in 
28 



434 ONYCHOSES 

trichophytosis; l>ut the distinction is not easy. Cultures of ungual 
trichophytons often fail for no known reason. 

The medical treatment of the onychomycoses consists in scraping 
as much as possible from the thickness of the nail and in having the 
patient wear every night for many months a dressing of cotton soaked 
in Lugol's iodin-iodide solution, covered with a rubber finger-stall 
which does not compress the linger. Various salves or ointments 
containing reducing or antiseptic agents may also be employed. 

Surgical treatment is more rapid, consisting in avulsion of the 
nails after local anesthesia; iodin-iodide dressings will prevent 
re-infection of the new nail. 

Onychoses of the Dermatoses. — There exists a pyococci*; onyxis, 
generally due to an association of staphylococci and streptococci; it 
might also be designated as impetiginous' onyxis (Fig. 139). 




Fig. 139. — Pyoroecic onyxis and'perionyxis of the right index finger and the left 
ring finger, of one year*s standing, in a girl aged ten years. 

Although attention has been called to it, notably by Sabouraud, 
it is not sufficiently known and is a frequent occasion of diagnostic 
and prognostic errors. It is encountered especially in children and 
youthful individuals, but also in adults, on one or several nails of the 
fingers or the toes. 

Pyococcic onyxis generally follows upon impetigo and especially 
upon panaris or whitlows; it extends beyond these conditions, its 
duration being much more prolonged, over a number of months. 
It begins as minute abscesses under the angle of the nail, which often 
dry without opening; they spread from one place to another in the 
vicinity in the nail-bed, more or less detaching the nail, which may 
itself become irregular, roughened and brittle, when the matrix has 
been invaded by the process. This onyxis is always accompanied by 



ONYCHOSES OF THE DERMATOSES 435 

perionyxis, namely redness, swelling and even pustulation of the 
peri-imgual folds. 

The treatment consists of local baths with Alibour water and 
moist dressings; later on, in applications of yellow precipitate oint- 
ment or various tar preparations. When properly treated, this 
affection is readily curable. 

Eczema of the nails is frequent, generally accompanied by eczema 
of the fingers and toes, as well as by perionyxis. The lesions are 
extremely polymorphous. There may be detachment of the nails 
with redness and subungual desquamation, longitudinal or transverse 
ridges with thickening, punctations, erosions, various deformities, 
etc. The treatment is that of eczema. 

The psoriatifarm eczematides and psoriasis give rise either to 
dotted cup-like erosions resembling the surface of a thimble, or to 
transverse and longitudinal striations, or to detachment beginning 
at one of the borders, etc. 

A positive diagnosis of eczema or psoriasis of the nail cannot be 
made without taking into account the concomitant lesions, but it 
must be kept in mind that onychosis may precede the cutaneous 
manifestations and often survives them. 

The treatment of psoriatic onychosis is very trying. Pyrogallol 
or chrysarobine salves, of 2.5 or even 10 per cent., may be employed. 
I prefer to paint the nails with a solution of one of these agents in 
ether or chloroform, or with some tarry solution, followed by cover- 
ing with plaster or a varnish. Radiotherapy is sometimes very 
efficient. 

In pityriasis rubra pilaris the nail is thickened, striated, literally 
like rush-pith, lustreless and yellowish; the thickening is due to 
a very hard although porous hyperkeratosis of the bed, which 
becomes conglomerated with the ungual plate. 

In ordinary alopecia areata, but especially in the extensive and 
generalized forms, ungual lesions are frequent, consisting of dryness, 
white longitudinal striation, punctation (pitted nail), or of Assuring 
(onychorrhexis) crumbling and indentation. 

In the severe primary erythrodermas, the nails become completely 
or incompletely detached (total or partial onycholysis) and in the 
last-named case, if a new nail is formed, it insinuates itself under 
the remains of the old nail. This partition of the nail is also seen 
after bruising, in syphilitic onyxis, etc. 

In pemphigus , chronic, foliaceous and hereditary, and in the grave 
forms of Duhring's disease (Fig. 140), the nails are usually involved, 
although in very different ways. The nail may fall without becom- 
ing replaced; in this case, the peri-ungual folds become obliterated 
and the bed is perfectly smooth ; or the nail is detached from before 
backward, or divided, or atrophied, or even onychogryphotic. 



43G 



ONYCHOSES 



In psorospermosis follicularis [Darier's disease], the nails are longi- 
tudinally striated, furrowed and brittle. 

Chronic radiodermatitis as an occupational disease gives rise to 
severe ungual lesions, consisting of fragmentation, destruction, 
exfoliation, or even total atrophy. 

Onychosis of General Diseases. -All severe or even mild pyrexias, 
eruptive fevers, typhoid fever, pneumonia, anginas, epididymitis, 
etc.; severe traumatisms or operations; emotional shock, childbirth, 
etc., may give rise to a groove or a transverse or rather bow-shaped 
ridge on the nails. All the nails or only some of them, especially 
the thumbnails, are thus marked to a variable degree. [The severe 
sea-sickness of an ocean voyage is capable of producing this effect 
on the nails.] 



J/E^/ tBL 






. ^/% vA 


ISM 




■■ 






fS ' ' tPKi 9^^ 




T^k 



Fig. 140. — Lesion? of the nails in a severe case of Duhring's disease. Definite loss 
on the index finger; atrophy on the ring finger and little finger; detachment, 
onychauxis and onychogryphosis on the thumb and middle finger. 

This groove results from an arrest or momentary disturbance of 
growth; it emerges under the supra-ungual fold a few weeks after 
the cause which has produced it, advancing toward the extremity 
at the rate of growth of the nail, namely about 3 mm. monthly. It 
furnishes a valuable indication to recent disturbances in the health 
of the subject. 

Chronic diseases, infectious or constitutional, may also interfere 
with the formation of the nails and cause atrophy, koilonychia, 
fissuration known as onychoschizis, simple hypertrophy known as 
onychauxis or scleronychia and onychogryphosis. 

Diseases of the pleiiropulmonary apparatus give rise to curva- 
ture with enlargement of the nails, known as the Hippocratic nail. 

Syphilitic Onyxis. Ungual lesions due to secondary syphilis are 
entitled to special mention on account of their diversity and 
importance. The condition is onyxis with or without peri-onyxis. 
Several varieties have been described by Fournier: 



DYSTROPHIC ONYCHOSES OF NERVOUS ORIGIN 



437 



The nail may be cracked [scabritees urigium] and brittle at its free 
end; or detached from below upward (onychoschizis) with non- 
painful redness and desquamation of the bed and sometimes loss 
of the nail; or considerably hypertrophied (pachyonyxis) , thickened, 
striated and blackish, without change of its general shape; or 
ulcerated (helconyxis) ; in the last-named case, the loss of substance, 
usually oval, crateriform and with lamellar borders, appears on the 
lunula and exposes the matrix or the bed of the nail, which is of a 
grayish-pink color. 

The peri-onyxis is said to be scaly or horny when a squamous 
papule forms on one of the peri-ungual folds; inflammatory, when 
it consists of a dusky red, very persistent tumefaction; ulcerative, 
when a loss of substance with cut-out borders and a sanious floor 
develops, often as a semicircle, on the peri-ungual folds. The extrem- 
ity of the finger is swollen and reddened; the nail usually falls out. 
Several fingers or toes are often attacked at the same time. 




Fig. 141. — Syphilitic onyxis. At the thumb, pachyonyxis and onychoschizis; 
on the index finger, a large deep groove; on the other fingers, cracked, fissured, 
crumbling nails. The syphilitic infection of this patient was of ten months' standing. 



These syphilitic onyxes and peri-onyxes (Fig. 141) are slightly 
painful, develop slowly and are subject to recurrence; they are apt 
to reappear in the course of the tertiary stage and prove very rebel- 
lious to treatment. Similar ungual lesions or more common ones 
are met with in congenital syphilis. 

Dystrophic Onychoses and Onychoses of Nervous Origin— Many 
nervous diseases involve the nails, notably the traumatic neuroses, 
syringomyelia, Morvan's disease, Raynaud's disease, tabes, hemi- 
plegia, scleroderma, etc. Perhaps the general diseases referred to 
above act through the mediation of the nervous system. 



438 ONYCHOSES 

The form of the lesions is extremely variable: simple falling-out, 

atrophy, detachment, fragility, deformity thickening, etc. 

All kinds of onychoses, the nature and origin of which could not 
be discovered, have commonly been referred to a trophic cause. 
I yield to this tendency in grouping here the four following forms: 

Leuconychia. -There exist two varieties of this affection: One is 
punctate and common in children, youthful individuals and women 
who take great care of their nails; it is characterized by small scat- 
tered or profuse white spots known under the name of fiores unguium, 
mendacia (gift-spots), or sometimes by linear series of spots which 
appear toward the lunula and advance with the nail. Nervous 
disturbances, some intoxications, etc., have been held responsible; 
but in my opinion they are the result of slight traumatisms of the 
ungual matrix. 

The other variety, leukonychia totalis, may be congenital or even 
hereditary; often it is acquired and occurs after a severe disease, or 
a neuritis, etc. There is also a striated variety, with alternately 
white and normal transverse bands. 

The whiteness of the nail is due in both types to fine bubbles of 
air which have become infiltrated between the probably imperfectly 
keratinized ungual cells. 

The patient should be instructed to avoid traumatism of the 
matrix of the nails, for example, in the manipulation of pushing back 
the supra-ungnal cuticle [and the use of the pernicious cuticle knife]. 
The nails can be tinted with an alcoholic solution of eosin. 

Onychogryphosis. — This name was given by Virchow to a 
deformity consisting of a sometimes enormous and very hard 
thickening, with a change in the direction of the nail, which becomes 
raised and curved on itself. The onychogryphotic nail of a low 
degree assumes the appearance of a very hard grayish or brownish 
claw, curved transversely and from before backward and raised 
from its bed by hyperkeratosis. 

In a higher degree, the nail is entirely deformed, convex and 
twisted, resembling a ram's horn. It is implanted almost vertically 
on its bed, of a brownish color and marked at the same time by 
longitudinal stria* and transverse undulating striae; the latter indi- 
cate the changed direction of the plane of the matrix. The nail 
grows slowly, but as its stony hardness prevents it from being cut, 
it often reaches from 3 to 4 cm. in length and exceptionally may 
attain a length of 10 and 12 cm. It is easily understood that it 
becomes troublesome in proportion to its size. 

Onychogryphosis is observed especially at the feet, on the big toe 
and sometimes on the neighboring toes (Fig. 142). It is less common 
at the fingers, where I have, however, seen several cases of it. The 
pathogenesis proposed by Virchow, who holds pressure from the 



ONYCHOSCHIZIS 



439 



shoes responsible for an irritation of the matrix, is therefore not 
tenable. Inflammatory lesions of the nail-bed, which were demon- 
strated by Unna, are perhaps secondary. It seems that a hyper- 
keratosis of the bed with hyperplasia of its papillary crests, accord- 
ing to Heller, raises and straightens the nail, which then grows 
thicker, but also more slowly. At any rate, this ungual dystrophy 
appears especially at a mature or advanced age ; it is almost regularly 
present on varicose limbs, bearing ulcers or the seat of elephantiasis; 
or it may coincide with chronic rheumatism, arteriosclerosis, neuritis, 
leprosy, etc. 

The palliative treatment consists of scraping, sawing, or tearing off 
the nail; it may first be softened by means of potash or salicylic 
acid. In order to prevent re-growths, it is necessary to excise the 
ungual matrix. 




Fig. 142. — Onychogryphosis of'the first three toes. 



Onychorrhexis. — Dubreuilh and others give this name to longi- 
tudinal striation with fragility of the nails. 

In pronounced cases, the nail is lustreless, cracked, roughened, 
thinned and broken. A few or all the nails may be involved. Ony- 
chorrhexis may date from childhood, or it may develop as a sequel of 
nervous disturbances, lichen planus, alopecia areata, etc. The nails 
may be painted with collodion to remedy the painful cracks and 
fissures. 

Onychoschizis. — This term (axtf «u = to separate) designates the 
detachment of nails from their bed. This separation is, as a rule, 
progressive and more or less rapid, with periods of remission and 
exacerbations. It begins under the free border and gradually 
ascends as far as the lunula; a single finger may be involved, or 
usually several fingers and toes are attacked simultaneously or 
progressively. Sometimes the separation is evidently dependent 
upon a subungual hyperkeratosis with accumulation of solid or 
friable horny material. 



140 ONYCHOSES 

Onychoschizis, like onychorrhexis and a considerable number 

of other changes of the nails, mentioned above, are undoubtedly 
not always of the same etiology and significance. Every case should 
be traced to its cause, if possible. 

General Diagnosis of the Onychoses. — Sometimes the objective 
features of ungual lesions, or the circumstances and coincidences 
are such that they can be referred to a definite cause from the start. 
Not infrequently, however, in clinical cases the etiology is neither 
apparent nor easily discovered. A hasty diagnosis of "trophic 
disturbance of the nails" — as is only too frequently made and merely 
amounts to an admission of ignorance — should be refrained from in 
such cases. When confronted with an onychosis of obscure char- 
acter, the physician must pass in review the different classes of lesions 
enumerated in this chapter, in order to find out where it belongs. 

It is well to remember the following facts: Malformations of the 
nails of congenital origin, or those connected with familial and hered- 
itary dystrophies may appear a fairly long time after birth; per- 
manent deformities of the nails may result from traumatisms which 
have damaged their matrix; onychomycoses of indefinite duration 
may occur without tinea, sycosis or epidermomycosis, and require 
microscopic examination; the onychoses of the dermatoses, pyo- 
coccia, eczema, eczematides, psoriasis, lichen planus, Duhring's 
disease, etc., not infrequently persist after the cutaneous manifes- 
tations have disappeared and may exceptionally precede them; 
syphilis and congenital syphilis require very careful investigations 
and sero-diagnosis. 

Finally, the discovery of chronic constitutional diseases (diabetes, 
etc.) or infectious diseases (tuberculosis, etc.), as well as nervous 
diseases, even abortive or incipient, may sometimes supply diag- 
nostic indications and suggest the proper treatment. 

A systematic review of this kind will considerably reduce the 
number of cases described as trophic disturbance of the nails, or 
trophoneurotic onychosis. 

The treatment must frequently utilize either keratolytic or reducing 
agents. Often, even in cases of enigmatic character, considerable 
benefit is obtained from high frequency currents and especially from 
radiotherapy. 



CHAPTER XXII. 
HIDROSES. 

The name hidroses (jdptoq = sweat) may be applied to func- 
tional disturbances of the sweat-secretion and to the primary 
organic lesions of the sudoriparous apparatus. 

The sweat glands are epithelial tubes whose deep or secretory por- 
tion is rolled up as a glomerulus, situated in the lower layers of the 
corium or the upper layers of the hypoderm; their ascending excret- 
ory portion, the so-called siveat-duct, passes directly through the 
derma and twists as a spiral in the epidermis. This channel opens 
obliquely at the surface through a pore. This arrangement of the 
pore and the sweat-channel and, moreover, the direction of the fluid 
which passes through them, oppose the penetration of dust and 
microbes into the interior, so that infections of the skin rarely occur 
by this route. 

The sweat-glands are distributed in unequal numbers over the 
entire integument, including the palmar and plantar regions, where 
they are indeed especially abundant. In the axillary fossae and in 
the anogenital region, they are of a special type, their secretory 
portion here having a very large lumen and serving as a receptacle 
for the sweat. 

The sweat is a watery fluid, of an odor varying according to body 
regions, individuals and races; usually of an acid reaction except in 
case of profuse sweating; in the axillae and in the groins, the reaction 
is normally alkaline. 

The quantity of sweat excreted in a given time varies enormously, 
and is influenced by temperature, exercise or rest, amount of bever- 
ages, action of the nervous system, as well as some -pathological 
conditions and medicinal agents. The average quantity is estimated 
at about a litre in twenty-four hours. 

Under normal conditions, the sweat evaporates in proportion to 
its production. Neither this insensible perspiration nor profuse 
sweating act as emunctories, but they greatly contribute to the 
regulation of the body temperature. Another function of the sweat 
is the maintenance of a moist and supple horny layer, as well 
through its watery content as through the emulsified fat contained 
in it. 

The chapter on hidroses is not of particular interest to the 
dermatologist. A distinction must be made between functional and 
organic hidroses : 



442 HIDROSES 

1. Disturbances of the sweat secretion, or junctional hidroses, 
belong to a considerable extent to the domain of general medicine. 

2. Organic lesions of the sweat-glands, or organic hidroses, are on 
the whole rare. 

Among the latter, hidrocystoma and hidradenoma will be described 
with the tumors; among the keratodermas, in a preceding chapter, 
mention has been made of porokeratoses or punctuate keratoses, 
which are without sufficient reason interpreted as ostio-sndoriferons 
keratoses. Dysidrosis and miliaria likewise have no definite 
relations with the sweat structures. The following discussion 
will accordingly be limited to sudamina, hidradenitis and miliary 
abscesses. 

FUNCTIONAL HIDROSES. 

The anomaly concerns either the quantity, or the odor, or the 
color of the sweat. 

Anidrosis. — Very exceptional cases have been reported of indi- 
viduals who do not perspire and therefore imperfectly regulate their 
temperature, as a result presenting symptoms of heat-stroke on 
even moderate exposure to the sun in summer-time. A striking 
observation of this kind was recentlv published by R. Lutenbacher 
(May, 1917). 

The sweat is very scanty in persons suffering from diabetes, 
myxedema, cachexia, ichthyosis, as well as in senile degeneration 
of the skin. Sweating is temporarily absent in several chronic 
erythrodermas, on the patches of psoriasis and in a considerable 
number of other eruptions. 

Hyperidrosis. — Individual differences in the amount of sweat 
excreted are such that hyperidrosis is never more than relative. 

The profuse transpirations which occur in the course or at the 
decline of the pyrexias, sweating or miliary fever, acute rheumatism, 
the sudoral form of typhoid fever, pneumonia, grippe, septicemias, 
etc., the sweats of phthisis, gout, or the moribund do not belong to 
the realm of this discussion. 

In a considerable number of organic or functional nervous diseases, 
in hemiplegia, tabes, neuritides, wounds of the nerves, lesions of the 
sympathetic, neurasthenia, exophthalmic goitre, etc., there occur 
profuse sweats, generalized or partial, permanent or in attacks. 
This is suggestive of a nervous pathogenesis in the so-called essential 
hyperidroses. Moreover, these are preferably observed in highly 
emotional individuals, or associated with obesity or auto-intoxica- 
tion. The sweat may exude all the time or, on the slightest effort 
or trifling emotion, moisten the surface of the skin, sometimes 
flowing in profuse drops. Maceration of the epidermis in the folds 
is a common sequel. 



FUNCTIONAL HIDROSES 443 

Hyperidrosis may be general, or more frequently partial, when 
it is known as ephidrosis. There is, for instance, a total facial ephid- 
rosis, or hemifacial or localized ephidrosis. The secretion in these 
patients may occur as a reflex under the influence of mastication 
or certain gustatory sensations, among others that of vinegar or 
chocolate. 

It is a familiar fact that bald persons usually transpire freely from 
the scalp and face ; I believe that this hyperidrosis is connected with 
kerosis and dependent upon its multiple causes (p. 196). 

The sweat of kerotic individuals is sometimes charged with such 
an abundance of emulsified fluid fat as to cause grease-spots on 
pillows, hats, paper placed on the skin, etc. These cases are desig- 
nated by the name of hyperidrosis oleosa. The condition is probably 
a combination of hyperidrosis with seborrhea oleosa (p. 393). 

The peculiar affection which bears the name of granulosis rubra 
nasi seems to be regularly associated with hyperidrosis and is prob- 
ably a result of the latter. It is observed especially in children and 
is characterized by small pinkish or red miliary papules on a lavender 
and cold background; the lesions occupy the nose and sometimes 
the lips or the chin; they become less marked with advancing years. 

The extremities are constantly moist or even wet with sweat in 
some individuals. When the hands are affected, a number of occu- 
pations are rendered impossible; at the feet, the excessive sweat 
macerates the epidermis, makes the skin very vulnerable, markedly 
impedes walking and often becomes offensive. Hyperidrotic ex- 
tremities are rarely warm and congested ; as a rule, they are cold, 
acro-asphyxiated and flabby, or of a waxy white color. 

Hyperidrosis of the articular folds, especially of the axillse, is 
extremely common; many obese, gouty, rheumatic or nervous 
individuals suffer from this condition. Axillary hyperidrosis may 
lead to lepothrix and to chromidrosis. It predisposes to intertrigo, 
to deep abscesses, etc. 

All dermatologists are familiar with hyperidrosis nudorum, a free 
flow of sweat from the axillae seen in patients who are stripped and 
exposed before an audience. In these cases, an excretory rather 
than a secretory reflex is concerned ; under the influence of cold and 
emotion, the smooth muscle fibers of the large axillary glands become 
contracted and empty their contents. 

Bromidrosis. — This name is applied to the offensive sweats which 
occur especially at the feet, sometimes in the axillse or groins, con- 
stituting a most distressing infirmity. 

Usually, but not invariably, bromidrosis is connected with hyper- 
idrosis and is a complication of the latter. It is possible for fatty 
acids or ammoniacal compounds to become eliminated in excess 
through the sweat, but as a rule the offensive odor is derived from 
secondary decomposition. 



444 hid roses 

In the treatment of hyperidrosis and bromidrosis, it is important 
not to neglect the correction of whatever may be deficient in the 
genera] hygiene of the patients. Locally warm or lukewarm baths 
are recommended; alcoholic rubs, for example with camphorated 
alcohol, or with alcohol containing iodin or tannin; and applications 
of ichthyol or various powders. 

< !ases of offensive sweating of the feet require scrupulous cleanliness, 
a frequent change of foot-wear, the wearing of shoes permeable to 
evaporation. Baths, alcoholic rubs, bland powders charged with 
salicylic or tartaric acids, or with bismuth subnitrate, are often 
inefficient. Formol, in all its forms, is dangerous. 

A good treatment of plantar hyperidrosis and bromidrosis con- 
sists in painting the parts daily with a solution of potassium perman- 
ganate (1 to 10 per 1000); or with iron perchloride solution with 
25 per cent, of glycerin. 

Still better results are obtained by painting the parts, daily at 
first, then at longer intervals, with a solution of chromic acid (2 per 
cent., or even 5 or 10 per cent.) followed by dusting with talcum- 
powder; but these applications must be very cautiously made. 

Against palmar hyperidrosis, radiotherapy has been shown by 
Sabouraud to be the cardinal remedy; sometimes, a single applica- 
tion of 5 units II. is sufficient. The same treatment is appropriate 
for granulosis rubra nasi. 

Chromidroses. — The problem of the chromidroses or colored 
sweats, to which several publications were devoted by Le Roy de 
Mericourt, still remains very obscure. Many of the reported cases 
are doubtful or simulated, but a few authentic observations are on 
record. 

The colored sweats are always regional, partial, or even very 
circumscribed; they may be blue, red, or black, or sometimes yellow; 
green, etc. The color as a rule is the result of oxidation on contact 
with the air of a chromatogenic agent contained in the sweat, which 
then becomes deposited on the epidermis in a pulverized form. 

A blue coloration is apparently due either to pyocyanin and 
coexistent with blue suppuration, or to indican. A red color is more 
common, especially in the axillae; it seems to be of microbic origin 
and is frequently associated with lepothrix. Dry erythidroses with 
adherent pigment have also been reported. The case of melanidrosis 
which was studied by R. Blanchard on the eye-lids of a thirteen-year- 
old boy confirms beyond a doubt the existence of this form. The 
black pigment which he saw becoming deposited around the sweat- 
pores was examined by Maillard and found to be related to the 
choroid pigment. 

Hematidrosis. — It is conceded that an oozing of blood derived 
from the capillaries may take place on the intact skin by way of the 



ORGANIC H1DR0SES 445 

sweat pores, hence the name which has been given to this phe- 
nomenon. The majority of the cases reported by the ancients, of 
bloody sweats under the influence of extreme emotional distress, are 
undoubtedly mythical. Perhaps the condition actually occurs in 
the course of severe infections, or in neuropathic individuals, in the 
presence of purpura, or as a vicarious menstruation. I am not 
acquainted with any convincing observations. 

ORGANIC HIDROSES. 

In a large number of dermatoses, the sweat-glands are affected 
together with the neighboring tissues, or secondarily. Primary and 
idiopathic affections of the glomeruli and sweat-ducts are on the 
contrary rare. 

It has previously been stated that in dysidrosis the sweat-glands 
play no part; also, that miliaria rubra and alba, although designated 
as sudoral eruptions on account of the conditions under which they 
are usually observed, are in reality a miliary impetigo without con- 
stant relation to the sweat glands (pp. 85 and 87). 

Sudamina [Miliaria Crystallina] is the name applied to an 
affection characterized by extremely minute bullous elevations of 
the horny layer, containing a clear watery fluid and without a con- 
gested base. 

The sudamina are the average size of a farina grain. Sometimes 
they are scattered in very variable numbers, sometimes grouped or 
even confluent in small blebs; they are observed on the trunk, 
notably on the flanks and abdomen, as well as on the flexor surface 
of the limbs. They appear suddenly without pruritus, altogether 
or in successive crops. Their duration is ephemeral; they dry out, 
the epidermis peels a little and all is well again. It is not impossible 
for a few small vesicles to acquire turbid contents and a slightly 
reddened base, as the sequel of a secondary infection which trans- 
forms them into miliary impetigo; but this is an exceptional 
occurrence. 

Sudamina have been encountered in the course of severe pyrexias, 
such as acute rheumatism, typhoid fever, scarlatina, at the crisis 
of pneumonia, or as a phenomenon preceding death. They are also 
observed to occur under occlusive dressings in the hot season, or 
in the course of treatment with keratoplastic agents. 

A sudamen, as shown by J. Renaut, is a small bleb situated in the 
horny layer or immediately below it, on the course of a sudoriparous 
canal. It may be interpreted as the mechanical result of splitting 
of this layer under the influence of a gush of sweat occurring after a 
temporary anidrosis with stagnation of the horny layer, or exagger- 
ated keratinization. The sudaminal contents are therefore probably 



IKi HIDROSES 

sweat, which by some authors was found to be alkaline or neutral, 
by others, including Jadassohn, invariably acid. 

No importance, not even a prognostic value, can be attached to 
this trifling lesion. 

Hidrosadenitis. — Verneuil (1864) described as phlegmonous hidros- 
adenitis or sudoriparous abscesses an affection commonly observed 
in the form of tuberous abscesses of the axilla (Velpeau) and which 
according to him may also be localized at the circumference of the 
anus, at the external auditory meatus, or even become disseminated. 

This condition is a form of staphylococcic pyodermatitis which 
will be described elsewhere in this book. It is usually admitted to 
result from an infection by way of the sweat-channels, although 
this fact cannot easily be demonstrated directly. [This disease 
should not be confused with hidradenitis suppurativa (Pollitzer), 
which is now included in the papulo-necrotic tuberculides.] 

Miliary Abscess of Little Children. — This condition has been 
known for a very long time and was already distinguished by 
Alibert from furunculosis. It occurs in neglected or greatly 
weakened infants suffering from impetigo, eczema of the buttocks, 
gastro-enteritis, bronchopneumonia, etc., and consists of multiple 
scattered resistant intradermic nodules, all of about the size of a 
small pea. On puncture a creamy pus is evacuated, their cavity is 
more or less deeply situated in the cutis. They occur in crops, some- 
times repeated; the general phenomena are very variable. 

The pyemic character of these abscesses was suspected in the past. 
However, Escherich and Longard surmised and Lewandowski (1906) 
demonstrated that they are in most cases the result of a staphylo- 
coccus aureus infection ; the infection takes place through the sweat- 
pores, a point of lessened resistance in the infantile skin. The almost 
invariable coexistence of small intra-epidermic pustules the size of a 
pin-head has been demonstrated, analogous to the ostiofolliculitis 
of Bockhardt, but due to infection of the sweat-pores and designated 
by Lewandowski as periporitis. 

As to treatment, incision of the abscesses is recommended, next 
sweating followed by sublimate baths of 1 per 10,000. Zinc sulphate 
baths of the same strength, or washes with Alibour water, would 
undoubtedly prove equally efficient. 



PART IT. 
NOSOLOGY OF THE DERMATOSES. 



In the first part of this book I have discussed the morphology of 
the dermatoses with a comparison of those related either by a com- 
mon eruptive lesion or pathological condition of the skin, or by a 
conformity, of localization in the same cutaneous or mucous territory 
or in the same organic adnexa of the epidermis. 

In the following part the dermatoses will be grouped according 
to their etiology, considering together those which are dependent 
upon the same kind of causes. 



CHAPTER XXIII. 
ARTIFICIAL DERMATITIDES. 

Inflammations of the skin resulting from the injurious action 
of a mechanical, physical, or chemical cause are called artificial 
dermatitides. 

Their clinical features are extremely variable; they may assume 
practically all the forms of dermatological lesions, especially those 
of erythema, urticaria, purpura, eczema, blebs, gangrene, etc. 

The severity of the lesions, their superficial or deep character, 
their more or less rapid or slow onset, their ephemeral or prolonged 
duration, depend in part upon the cause and in part upon the soil 
on which it has acted. The cause may in itself be more or less 
markedly injurious; its action may have been more or less intense or 
persistent. The soil, namely the damaged skin, in its turn presents 
variations in vulnerability and capacity of reaction according to the 
patient and the region of the body. 

Those relatively rare cases must be separately classified in which 
there exists what Brocq calls (July, 1915) a diminished resistance of 
the skin, which may be congenital or regional; this abnormal vul- 



Ms ARTIFICIAL DERMATITIDES 

nerability — which is the basis of congenital pemphigus, hydroa 
vacciniforme and xeroderma pigmentosum, but which I have 
observed also outside of these affections — often manifests itself only 
toward a certain class of injurious agents (traumatism, light, etc. I. 

In normal individuals, it may be stated that the influence of the 
patient's individuality, his persona] equation, what is known as the 
morbid predisposition, is relatively slight in the case of most dermat- 
itides of mechanical and physical origin; whereas this predisposition 
plays on the contrary a leading part in the pathogenesis of dermat- 
itides 'of chemical origin, or toxidermas. It will be more fully 
considered in the section devoted to the latter. 

It must be understood that there is no absolute and constant 
agreement between cause and effect in the artificial dermatitides. 
From this rule are derived the two following corollaries: 

The same injurious agent may give rise, in different cases, to 
fundamentally dissimilar eruptions. The dose, the avenue of inva- 
sion, still other factors and especially the individual predisposition 
strongly modify the consequences of the same cause. In this way, 
to quote an immediate example, the absorption of an iodide may 
give rise, in different cases, to erythema, urticaria, purpura, bulla?, 
pustules, etc. 

Inversely, dermatitis of identical appearance may be derived 
from entirely different injurious causes. A bullous dermatitis, for 
instance, may be the result of a burn, the application of a blistering 
or caustic substance, or the absorption of a medicinal agent such as 
an iodide or antipyrin. It could not be otherwise, for while injurious 
agents are extremely numerous, the modes of reaction of the skin are 
limited in number. 

In dealing with a given cutaneous lesion, the clinician is therefore 
often puzzled at its origin. It is precisely this difficulty which lends 
interest to the artificial dermatitides which are extremely common. 

I shall successively review (1) dermatitides due to mechanical 
causes; (2) dermatitides due to physical causes; (3) dermatitides 
due (or apparently due) to chemical causes, which may be called 
toxidermas; these should be subdivided into two groups, according 
to their external or internal origin. It seems advisable to add to the 
description of the latter a comment on the autotoxic dermatoses, 
which although not artificial may pass as toxidermas. 

DERMATITIDES DUE TO MECHANICAL CAUSES. 

Traumatisms of all kinds, when slight, may give rise to erythema 
(Chapter I). More severe traumatisms cause contusions, wounds, 
etc., in short, surgical complications. 

The following belong to the domain of dermatology: Traumatic 



DERMATITIDES DUE TO MECHANICAL CAUSES 449 

eczema (Chapter IV) ; excoriations from scratching and the epi- 
dermic hypertrophy known as lichenization; the latter will be 
discussed in the chapter on Pruritus (Chapter XXIV); certain 
traumatic alopecias; and furthermore, the effects of repeated or 
prolonged pressure. 

Strong and persistent pressure on some part of the skin, like that 
exerted by a badly fitting plaster apparatus, gives rise at first to 
erythema, then to phlyctinization, finally to ulceration and even to 
gangrene. 

Repeated pressure with friction on a thick epidermis, like that 
produced on the foot by hard shoes during a long march, or on the 
hand by the manipulation of some tool or instrument, causes the 
appearance of bullous elevations known as traumatic blisters, well 
known to soldiers, mountain-climbers, boatmen, acrobats, etc. 

Attention is here called to the special vulnerability of the skin 
which constitutes congenital pemphigus (p. 191). 

Callus. — Callus or callositas represents a chronic traumatic der- 
matitis with thickening of the derma and hyperkeratosis. Callosities 
are observed on the hands of laborers, where their seat often betrays 
the occupation of the individual (diggers, gardeners, blacksmiths, 
tailors, etc.); on the feet, notably on the instep and at the ankles; 
moreover, on the prominence of the head of the first metatarsal in 
case of hallux valgus, where they contribute toward the formation 
of bunions; on the ischial bones of cavalrymen, etc. In short, 
callosities may form at any point on the body. 

Callus is a yellowish or pigmented prominence of variable extent, 
round or oval, with gently sloping borders, thick and solid on palpa- 
tion. Being a defensive reaction of the integument, the callus is not. 
painful either spontaneously or on pressure unless it is inflamed. 
In this case — the "durillon force" of Chassaignac — a blister may form 
underneath the thickened epidermis; when it becomes infected, the 
subepidermic abscess often gives rise to lymphangitis with fever, 
so that the patient is obliged to stay in bed. 

The only treatment of simple callus consists in the suppression 
of its cause. Moist dressings and rest are the measures most to be 
recommended in case of inflammation. 

Clavus. — A corn or clavus is a local traumatic hyperkeratosis 
with inflammation, then atrophy of the cutis, occurring only on the 
feet, at points exposed to chronic pressure from badly fitting shoes. 
It is situated especially on the prominence of the phalangeal articu- 
lations of the toes, particularly on the little toe, or on the metatarsal 
prominences and sometimes on the sole of the foot. Its dimensions 
vary from those of a lentil to a small bean. Corns are always painful, 
either spontaneously in damp weather, or on pressure when they are 
not trimmed. 
29 



450 ARTIFICIAL DERMATITIDES 

Corns differ from callosities in the much greater thickness of their 
horny layer which projects as a smooth or scaly prominence and is 
deeply embedded in the cutis; the latter is depressed like a funnel 
and inflamed or atrophied. In the center of the horny mass a softer, 
white, medullary portion can often be distinguished, formed by 
poorly keratinized cells. Underneath the corn the malpighian layer 
is thinned and the papillae are obliterated. Occasionally the center 
of the corn presents a papilla with dilated vessels projecting into the 
horny mass. The so-called "root" of the corn has no actual exist- 
ence and its extraction by quack chiropodists is nothing but a trick. 

[nterdigital corns, known in France as "ceil de perdrix" (par- 
tridge eyes), are softened as the result of maceration [soft corns]. 

Corns must not be confused with plantar warts or with mal 
perforans. 

To be afflicted with corns may mean an extremely distressing if 
minor infirmity, for which patients are apt to neglect seeking pro- 
fessional advice. Left untreated and irritated by pressure, corns 
may become the seat of an inflammation, a blister, an abscess, etc. 
When badly cut, they often give rise to lymphangitis. 

The popular treatment consists in trimming the hyperkeratotic 
layer with a razor at regular intervals before it again becomes 
exuberant and painful, as well as in avoiding all local pressure. The 
horny mass may also be softened by nocturnal moist dressings, or 
by keratolytic agents such as salicylic acid plasters, or salicylated 
collodion, which permits the removal of the corn in a warm 
bath. Without patient and persistent treatment, a relapse is very 
probable. 

DERMATITIDES DUE TO PHYSICAL CAUSES. 

Heat, cold, solar and electric radiations, x-rays, beyond a certain 
limit, are injurious to the human integument. They give rise to a 
series of lesions, that range from erythema to gangrene. Super- 
added pyococcic infections frequently complicate the clinical 
picture. 

Aside from these general data, which apply to all, it is noteworthy 
that especially in regard to light radiations, certain individuals are 
much more susceptible than others (solar erythema, pigmentations) ; 
also, that there actually exist special pathological conditions (herpes 
vacciniformis, xeroderma pigmentosum) characterized by dispro- 
portionate reactions to the effect of light. 

Burns. — Burns may be produced by burning or incandescent 
bodies or by heated substances, solid, liquid, or gaseous. Lesions 
caused by bright light, electricity, or caustic agents, are often placed 
in the same group. 



DERMATITIDES DUE TO PHYSICAL CAUSES 451 

Three degrees of burns are recognized: 

In the first degree, the lesions consist of erythema, with severe pain, 
heat, swelling, representing erythema a calore. In a few days, after 
desquamation, the skin is well again. 

The second degree is characterized by bulla? . These form either 
immediately, the vaporization of the intramalpighian plasma having 
raised the horny layer under which a certain amount of serum 
collects; or secondarily, after a few hours, through the mechanism 
of superficial or deep bleb-formation. The contents of the bullae, 
which vary greatly in size, are lemon-yellow, fluid or gelatinous. 
The pain is extremely severe. The bullae having ruptured, the fluid 
escapes and a bright, red, shining surface appears under the epidermic 
membrane; or they may shrivel and dry in crusts; or they may 
become infected and suppurate. In the last-named case, a cicatrix 
may persist. The course of healing lasts one or two weeks. 

In burns of the third degree, there is sloughing, coagulation and 
necrosis of the cutis and sometimes of the subjacent parts. Blisters 
appear only on the borders of the slough which in different cases 
is yellowish or brown, or dry and anesthetic. The pain may be less 
severe than in a burn of the second degree, on account of destruction 
of the nerve-ends. The course, of very variable duration according 
to the depth and extent of the burn, the region affected and the 
evactual complications, is that of a non-progressive gangrene. The 
cicatrix is often vicious. 

Very extensive burns, like those of children who have tumbled 
into a boiler, or of soldiers struck by an incendiary shell, or those 
which I saw after the fire of the Puteaux powder mills, where the 
unfortunate women workers were burned from head to foot except 
on the parts protected by the corset, are accompanied by grave 
general symptoms. Chills, fever or rather a lowering of the central 
temperature, collapse or delirium, bloody vomiting, melena, albu- 
minuria and pulmonary complications are due in such cases for the 
most part to toxic products resulting from the alteration of the 
blood in the cutaneous vessels, under the influence of heat; in part 
to the nervous shock and finally to superadded infections. Burns 
involving over one-third of the total tegumentary surface are 
usually fatal. 

The treatment of burns consists in cleansing the skin, in the evacua- 
tion of the blisters without pulling off the epidermis, in the appli- 
cation of sterile occlusive dressings. Packing in aseptic cotton, 
after painting with dilute tincture of iodin (1 to 2) constitutes 
an excellent procedure of immediate treatment; if necessary, the 
clothing must first be cut away. 

Among the countless topical applications which have been 
recommended, including even raw scraped potato and gooseberry 



452 ARTIFICIAL DERMATITIDES 

jelly, which actually relieves the pain, the preference must be 
accorded to oil- and lime-water liniment, vasolanolin, naftalan, or 
better still, to the special oils named pyrolcol and phlyctol, which 
are highly analgesic. The burn is covered with sterilized com- 
presses soaked in one of these products and with a thick layer of 
cotton. The dressings should be changed as rarely as possible, 
except in case of suppuration. Ichthyol, glycerinated thiol, the 
salve of J. Lucas-Championniere and the product named ambrine, 
can also be recommended. Picric acid which has found so much 
favor, should be rejected, for it is sometimes dangerous. 

In case of very extensive burns, permanent lukewarm baths give 
the most relief. It goes without saying that an injection of mor- 
phin should not be refused to these unfortunates in their atrocious 
sufferings. Camphorated oil and adrenalin by subcutaneous injec- 
tions and enemas with physiological salt solution, are indicated in 
grave cases. 

Frost-bite. — Lesions caused by freezing differ in many respects 
from those due to extreme heat. Cold requires a longer time for 
its action. Immediate pain is practically absent and nothing is felt 
but an unpleasant numbness; pruritus and an intolerable burning 
sensation being delayed until the reestablishment of the circulation. 
It is almost invariably the extremities that are attacked by frost- 
bite; the feet, the hands, the ears and the nose. In the first degree 
the region is of a cadaveric pallor, followed by intense congestion. 
The second and third degree, bleb-formation and sloughing, usu- 
ally exist together, the lesions attaining their maximum at the 
periphery, at the tips of the toes, the fingers, etc. The integument 
is at first of a waxy color, the region is anesthetic and lifeless. It 
is impossible to determine to what depth the tissues are affected 
till after a few days. 

The frozen parts must be very cautiously and progressively 
warmed, preferably by rubbing them with snow; they may be 
covered only very gradually and the surrounding temperature 
raised very slowly. The subsequent course and the treatment are 
the same as in gangrene of any origin. The physician's attitude 
should be as conservative as possible and surgical intervention be 
restricted to the removal of a sequestrum. Frost-bites may lead 
to grave mutilations. 

Chilblains and trench-foot have been discussed elsewhere in this 
book (pp. 34, 35). 

Radiodermatitides. — The .-c-jrays as well as radium, mesothorium, 
etc., although causing no sensation whatever at the moment of 
application, may give rise to a series of cutaneous manifestations, 
the extreme degrees of which are very grave. However, as there 
seems to be no individual idiosyncrasy toward these radiations, 



DERMATITIDES DUE TO PHYSICAL CAUSES 453 

these disturbances can always be avoided. They depend exclu- 
sively upon the dosage and quality of the rays. It is therefore of 
the utmost importance for radiologists to employ all measuring 
instruments belonging to an outfit of this kind, to be entirely 
familiar with the peculiarities and strength of their apparatus, to 
calculate accurately without mistakes the distance from the anti- 
cathode to the skin as well as the time of the exposure. 

Unfavorable sequelae of .r-ray treatment and the occupational 
radiodermatitides of radiologists themselves will be discussed 
separately in the following. 

Therapeutic Radiodermatitides. — The cutaneous reactions due to 
the x-rays do not appear until after a period of latency or incuba- 
tion, lasting from eight to twenty days, usually from fifteen to 
seventeen days. The slight redness which may supervene on the 
same day or the day after the session is an erythema presumably 
due to the light rays and is of no importance. 

Alopecia of the scalp regularly appears upon a dose of 5 H, so 
that Sabouraud was enabled to formulate the radiotherapeutic 
treatment of the tineas. On the face and elsewhere, alopecia is 
not a constant result and is often complicated by pigmentation and 
cutaneous atrophy. 

Beyond a dose of 5 H in a single session, or if exposures of the 
same point are repeated beyond the ratio of tolerance as established 
by experience, there is danger of a series of manifestations, to be 
enumerated in the following: It must be kept in mind in this con- 
nection that the .T-rays have a cumulative effect; that nevertheless 
there is a loss with time, differently estimated by authors, but which 
can be rated at 1| H weekly; finally, that certain regions are 
especially susceptible, notably the back of the hands and feet, the 
bridge of the nose and the forehead — perhaps all points where 
the integument rests upon a bony surface. 

The erythema, the first degree of radiodermatitis, punctiform and 
pink at the onset, later on becomes a uniform dusky or purplish 
red; it gives rise to severe itching, then to desquamation, lasting for 
a few days to a week, rarely longer. 

The erythema is usually followed by pigmentation which may last 
for months, varying greatly in different individuals. 

Blebs, scattered, grouped, or confluent upon an erythematous 
base, may develop after a more energetic exposure and are often the 
forerunners of ulcers or sloughs. 

Ulceration usually burrows on the floor of a bleb which has 
suppurated. It is dusky red, smooth or slightly granular, with 
gently sloping borders, of extremely variable shape and extent, with 
scanty serous oozing. It is accompanied by burning, tearing, 
lancinating pains, often of extreme severity, preventing sleep and 



454 ARTIFICIAL DERMATITISES 

constituting a serious torment. Radiodermatitic ulcers take a 
sluggish course, first progressive, then slowly retrogressive; they 
often last several months or even years. I have pointed out that 
sometimes they may simulate superficial epitheliomas, biopsy being 
necessary for a diagnosis. 

Sloughing develops primarily, or under a blister, or around an 
ulceration. The slough is white, then brown or black, hardly 
encroaching upon the cutis or on the contrary also involving the 
cellular tissue, the tendons, the aponeuroses, etc-., briefly, all the 
subjacent parts. It causes frightful pains, radiating to a distance, 
of a neuritic character. The course is very slow; demarcation and 
elimination are long delayed. Relapses, with reproduction of 
sloughs at the periphery or below are not uncommon. A cure 
requires months and may be followed by recurrences in situ. A 
very instructive case of ulcerative radiodermatitis came under my 
personal observation and was published in the Annates de Derma- 
tologie, October, 1913. An ulcer on the breast of a young woman, 
occurring six months after a final .r-ray session, healed in five months; 
it reappeared spontaneously, without a new radiation, over eleven 
years afterward and at this time still presented the histological 
structure of a recent radiodermatitis. It must be concluded that 
the pathological process persists practically indefinitely. 

The patches of sclerous radiodermatitis which follow upon an ulcer, 
but may also develop as the sequel of a simple erythema or bleb, 
have a pathognomonic appearance. There is an indistinctly out- 
lined spot of white, tense and indurated sclerosis, smooth and 
interspersed with serpentine or arboreal telangiectases; or there 
may be an undulating, scaly, lardaceom surface, mottled with pig- 
mentary spots and purplish macules, adherent and not readily 
folded; finally, a thickened and deformed genuine cicatrix may be 
present. These three degrees of lesions may coexist in concentric 
zones. 

Observers have been impressed with the analogy between the 
patches of white or lardaceous sclerosis in radiodermatitides and 
scleroderma in patches, which, however, is more sharply outlined; 
and also with xeroderma pigmentosum and senile degeneration, but 
the last-named affections are diffuse and regional (Chapter XVII). 

Complications due to overexposure to the .r-rays should no longer 
occur at the present day. Before any new application, it must be 
kept in mind that the patient may forget to mention, or try to 
conceal a recent .r-ray treatment. Careful inquiries must therefore 
be made. 

Occupational Radiodermatitides. — Radiologists, unless carefully 
observant of the most scrupulous precautions, are exposed to a 
diffuse, insidious, chronic and progressive radiodermatitis, which is 



DERMATITIDES DUE TO PHYSICAL CAUSES 455 

always grave and may become fatal. The hands, sometimes the 
face, are the parts naturally most affected. The fingers at first 
become cyanotic; the epidermis becomes dry and peels off, the 
skin becomes swollen and cracked, retracting especially around the 
nails which likewise become furrowed, split, break and exfoliate. 
The patient has a constant feeling of constriction. 

The appearance, which is at first suggestive of frostbite or of 
dysidrosis, later on approximates that of the eczematized prurigos; 
but the mixture of atrophy, telangiectasis, verrucosities, etc., on 
the other hand, lends the clinical picture an analogy with xeroderma 
pigmentosum and with arsenical keratosis. 

The occurrence of epithelioma of the papillary, later the lobu- 
lated type, is not very rare in these chronic radiodermatitides. 
It cannot be stated outright that x-rays give rise to cancer, but it 
must be admitted that their cumulative effect leads to a cutaneous 
dystrophy on which epithelioma more easily develops in the same 
sense as on the senile, arsenical, xerodermic dystrophies, or on 
cicatrices in general. The pioneer radiologists who worked at a 
time when the remote dangers of the x-rays were still unknown, 
have nearly all expiated their unwitting lack of caution with severe 
mutilations and in some instances with their lives. 

Treatment. — This must be primarily prophylactic. The applica- 
tion of x-rays and radium requires scrupulous attention and con- 
siderable experience and caution. It must moreover be kept in mind 
that those cutaneous regions which have once been overexposed 
retain indefinitely a remarkable vulnerability toward mechanical, 
physical, chemical and medicinal noxious agents and especially a 
susceptibility to x-rays; they suggest fire smouldering under the 
ashes. 

Erythema or blebs are treated like burns. Against the pigmen- 
tations, hydrogen peroxide or naphthol creams may be employed. 
Occupational radiodermatitides, sclerotic radiodermatitides and 
ulcers do well under repeated baths and moist occlusive dressings, 
notably a chamomile infusion mixed with potash, 1 per 10,000; 
inunctions with vaselin-lanolin cream and lead-water, or with 
glycerol of starch. Stimulating, antiseptic, analgesic topical appli- 
cations and reducing agents in general should be avoided. Oily 
dressings are often readily tolerated. 

Static baths, high-frequency currents and even heliotherapy 
have been recommended, but cannot be unconditionally endorsed. 
In certain cases, the excision of an ulcer may be indicated when 
this is feasible, or the destruction through superheated air. [Radi- 
cal surgical excisions of deep x-ray ulcers followed by grafting not 
only gives prompt relief to the intolerable pains but is the best 
insurance against the subsequent development of epithelioma.] 



456 ARTIFICIAL DERMATITIDES 

Of recent years, especially in America, attempts have been made 
to treat the spots of keratosis and the incipient epitheliomas of 
radiologists, through applications of radium. This paradoxical 
therapy, which has the advantage of being painless, seems to have 
yielded really successful results. 

TOXIDERMAS. 

The number of substances of all kinds which may damage the 
skin is so great, their effects are so multiple and variegated that 
an entire volume might be devoted to this subject without exhaust- 
ing it. I shall limit myself to a consideration of those features 
which have the most important practical bearing. 

Etiology. — In the etiology of the toxidermas we have to deal 
not only with poisons, a group of substances actually incapable of 
definition, but also with countless medicinal agents, the list of 
which is extended every day through the achievements of chemistry, 
as well as many products employed in the industries, in the house- 
hold, for the care of the person, etc., and finally a certain number of 
foods and drinks. 

According as the injurious substance has acted through appli- 
cation or friction on the skin, or by its having been ingested and 
absorbed, a distinction is made between: External toxidermas, or 
the direct artificial eruptions of Bazin, on the one hand; and the 
internal toxidermas, or indirect artificial or pathogenetic eruptions 
of Bazin on the other. 

In the latter case, the digestive mucosa most frequently serves 
as the avenue of entrance; exceptionally, the urogenital, respiratory, 
or even the conjunctival mucosa may be responsible; finally, the 
injurious substance may have been introduced by the hypodermic 
route, which is becoming more and more used for therapeutic 
purposes; eruptions due to sera form an interesting group of this class. 

Symptoms and Diagnosis. — A few general remarks will suffice in 
this connection. 

Three points have to be settled: (1) The presence of a toxi- 
derma; (2) its external or internal origin; (3) the discovery of the 
injurious substances. 

1. As there exists no characteristic sign of toxidenna in general, 
the prudent physician will make it his rule, when dealing with any 
dermatoses the diagnosis of which is not at once evident, to think 
of the possibility of an artificial eruption and to pursue his inquiry 
in this direction. 

It would be a mistake to assume that the eruption is the 
entire disease in the toxidermas. Accessory pathological phenomena 
are frequent. Aside from the painful, burning, tense and espe- 






TOXIDERMAS 457 

cially itching sensations which usually accompany the eruptions, 
general disturbances may also be observed, such as malaise, excite- 
ment, headache, insomnia, various digestive disturbances, a pale 
or yellowish complexion, etc. Fever may be associated with these 
symptoms; it is usually moderate and ephemeral; exceptionally it 
may be very high. 

The internal toxidermas are accompanied in certain cases by 
enanthema of the buccal, pharyngeal, nasal, conjunctival, genital 
mucosae, sometimes even by edema of the larynx; this may be not- 
ably the case in iodism, hydrargyria, etc. It follows from this 
fact that the differential diagnosis of certain toxidermas from the 
eruptive fevers or from various infections derived from a mucous 
membrane, may present very serious difficulties. 

2. The external or internal origin of a toxiderma is sometimes 
evident at the first glance ; the type of the eruption, its topographical 
distribution, its localization or generalization may furnish valuable 
indications in this respect. In other cases, however, this question 
cannot be settled off hand. It may happen that a substance applied 
to the skin acts both locally and by absorption. Hence the boun- 
dary between the external and internal toxidermas is not absolute. 

3. In the determination of the injurious agent, it is essential not 
to overlook the following considerations: Among the various 
eruptions which may be caused by the same substances some are 
specific, plainly characteristic of the cause which has produced 
them (example: some bromide eruptions, some antipyrinides and 
arsenical keratosis); others are less characteristic and justify only 
a presumptive diagnosis (example: iodide acne, bromide acne); 
still others are commonplace, resulting from the action of many 
different kinds of substances (example : urticaria) . 

It is a matter of common observation that a given individual 
reacts to the same substance by an always identical eruption, 
without a proportion necessarily existing between the dose and 
the degree of the reaction. Frequently also the same individual 
reacts by the same eruption toward several different substances. 
It seems in such cases that the patient makes the eruption, the 
injurious substance merely playing an accidental determining part 
which elucidates and reveals, as it were, an existing pathological 
tendency. Its action has been likened to that of the fingers on the 
trigger of a loaded gun. It goes without saying that the artificial 
eruptions which appear under the influence of a variety of causes, 
are necessarily of an ordinary form. 

Pathogenesis. — The pathogenesis of the toxidermas must be 
studied from the standpoint of: (1) The conditions under which 
the injurious action of certain substances is developed; (2) the 
mechanism of their action. 



158 ARTIFICIAL DERMATITIDES 

1. CONDITIONS OF INJURY— The nature-of a substance— its 
chemical properties — sometimes account for the action which it 
exerts upon the skin; this is true for the caustic agents, for sub- 
stances having a strong reducing or oxidizing action, etc. 

In other eases, substances arc concerned which possess special 
biological properties and under these conditions one must essen- 
tially remain satisfied with the phrase: Quia est in eis qucedam 
virtus. . . . The vesicants or rubefacients belong to this group. 

Provided that the conditions of dosage, concentration and dura- 
tion of action are present, the substances in this first class are 
sure to affect any human skin, without a predisposition of any 
kind being required. The resulting dermatitides are external toxi- 
dermas through direct contact and may be designated as traumatic 
toxidermas or chemical dermatitides (example: sulphuric acid, croton 
oil, etc.). 

Other external or internal toxidermas are due to bodies whose 
chemical character and general biological properties do not explain 
this influence, which moreover is exerted only in an inconstant, 
accidental, even exceptional manner, so that one is compelled to 
attribute the abnormal reaction to conditions of territory, intoler- 
ance, or individual susceptibility. 

As a matter of fact, there exists no sharp boundary line between 
the groups of substances acting on all persons alike (example: 
caustic potash), those acting on many persons (example: carbolic 
acid), or those acting only exceptionally (example: iodoform). 
However, in the presence of an inconstant effect, not explained by 
the conditions of quality, quantity and duration of action, one 
must necessarily suspect the intervention of a personal factor, a 
special susceptibility, or a peculiar capacity of reaction. This is 
what is meant by predisposition. 

Predisposition and Idiosyncrasy. — The question of predisposition 
to disease, which is connected with that of immunity, has a scope 
far exceeding the limits of a book of this kind. The problem may 
be studied from a general point of view in connection with infec- 
tions, intoxications, nutritional diseases, etc. I have frequently 
had occasion to allude to predisposition in other chapters, but as 
it plays the most evident part in the toxidermas, a few lines will 
here be devoted to its discussion. 

In the first place, it must be emphasized, with Jadassohn, that 
the term predisposition is applied to two phenomena which up to 
a certain point are distinct: 

1. Increased sensibility, or hyyersensibility, causing a given indi- 
vidual to react to a minimum dose, greatly below that which is 
generally injurious, but the form of the reaction is not unusual. It 
has been stated that in case of hypersensibility, the question of 



TOXIDERMAS 459 

dosage of the injurious agent is of no importance, but this is 
obviously an exaggeration. 

2. Idiosyncratic intolerance, in which an individual experiences 
injurious effects from a given substance which it would not produce 
in any dose on a normal individual. 

It is not always possible to decide which of these phenomena is 
concerned in a special case; moreover, there exist varieties inter- 
mediate between these two forms of predisposition. 

In current usage, the word predisposition is employed rather for 
a sensibility the reasons of which are suggested by a disturbance of 
the general health ; when the cause of the intolerance is absolutely 
mysterious, one resorts to Greek and speaks of idiosyncrasy. 

The real nature of so-called predisposition is unknown. Clinical 
experience teaches that it may be: general, the skin proving sus- 
ceptible to all irritants; or special, intolerance existing only toward 
a single substance or group of substances; absolute or relative, 
namely more or less independent of the dose and the mode of 
introduction. A medicinal agent is sometimes tolerated when it is 
ingested or injected, but proves injurious on external application; 
this is common with mercury and the rule with iodoform, for 
instance. It is noteworthy that poisons when ingested reach the 
skin in a lower concentration, especially as the liver retains a 
considerable share. 

Predisposition is congenital and sometimes even familial, or 
acquired. It is finally either permanent or temporary and may 
recur a number of times. 

The causes of the intolerance are generally obscure, frequently 
multiple and inextricable. 

Often a general disturbance must be held responsible, due to an 
infectious disease, physical or mental overstrain, a physiological 
phenomenon such as menstruation, pregnancy, the menopause, etc. 
A local irritation or infection may invite a toxiderma; seborrhea 
and acne vulgaris are known to predispose to iodide, bromide and 
tar acne, just as dental caries and gingivitis provoke mercurial 
stomatitis. 

Digestive disturbances, preexisting or caused by the toxic agent 
itself, favor the development of toxidermas; changes in the gastro- 
intestinal motility, secretions, fermentations, etc., may lead to 
absorption of abnormal products or to a reaction of these products 
on the medicinal substance. In the bromide and iodide eruptions, 
for instance, the role of digestive disturbances seems probable. 

In other cases, hepatic inefficiency or renal insufficiency are held 
responsible, meaning a diminution in the antitoxic function of the 
liver or the excretory action of the kidneys; or functional disturb- 
ances of the cardiovascular apparatus, the nervous system, or the 



460 ARTIFICIAL DERMATITIDES 

glands of internal secretion may sensitize the skin or bring about 
one or another eruptive form and localization. 

Idiosyncratic intolerance may subside in some cases under a 
gradual and continuous administration, with establishment of 
habituation or nrithridatization. One may assume that the skin 
has acquired a greater resistance, or that elimination through the 
emunctories has improved, or that an immunization has occurred, 
of which the phenomenon of so-called anti-anaphylaxis is undoubt- 
edly an example. 

The opposite is noted in respect to certain bodies which are cap- 
able of accumulation in the organism. Digitalis, bromin, arsenic, 
chloral and even iodin, etc., are known to belong to this group. 
However, accumulation accounts only to a very limited degree for 
idiosyncrasy. 

The usual course of events is as follows: An individual, appar- 
ently free from anomalies, is attacked, in consequence of the appli- 
cation or ingestion of some alimentary or medicinal substance, by 
an eruption of an erythematous, urticarial, eczematous or other 
type. 

If he has never before absorbed this substance or come in con- 
tact with it, the case belongs simply to the class of idiosyncratic 
intolerance. Sometimes, however, he has previously tolerated it 
without disturbance. In the latter case, whether the toxidermic 
attack has occurred at the time of one of the disturbances mentioned 
above or in the absence of a demonstrable adjuvant factor it is 
almost the rule for this individual to be thereafter, for a fairly long 
or even indefinite period, hypersensitized to such a degree that the 
most minute dose of the injurious body, or perhaps of several others, 
will give rise to a fresh eruptive attack. 

This acquired sensibility has very naturally been interpreted by 
some as a peculiar instance of anaphylaxis, to which we must devote 
a few words. 

Anaphylaxis. — Ch. Richet discovered (in 1902) and gave this name 
to the special sensibility produced by the preliminary injection of 
certain toxalbumins; it differs from the accumulation of toxic agents 
in not manifesting itself immediately but only after a certain 
period of incubation. The conditions under which he observed this 
phenomenon and the principal facts concerning it are as follows: 

Experimenting on dogs with the poison of actinia [sea-anenomes], 
Richet demonstrated that an animal injected with a sublethal dose 
will recover; a new similar dose injected a few days later remains 
without effect; but if at the end of two to three weeks the same dog 
is injected with an even ten or twenty times smaller dose, he will 
suddenly develop very serious or even fatal symptoms. These 
symptoms, the essential phenomenon of which is a sideration of 



TOXIDERMAS 461 

the nervous system with lowering of the arterial pressure, constitute 
the "anaphylactic shock." Richet assumes that the first injection 
has stimulated in the blood the formation of a toxogenin, which on 
contact with a new dose of its antigen combines with it to form a 
powerful poison, the apotoxin. 

The experiments of Arthus, Theobald Smith and others have 
shown that this anaphylactogenetic power belongs not only to 
toxic agents, but that the injection of the blood-serum of an animal 
into an animal of another species will similarly sensitize it toward 
this serum. It is now known that in a general way all albuminoid 
substances will produce anaphylaxis. 

In addition to this direct and "active" anaphylaxis, Richet dis- 
covered that there exists a "passive" anaphylaxis, in so far as an 
animal may be sensitized by injecting into it the serum of a sensi- 
tized animal. I have previously mentioned that the discovery of 
passive anaphylaxis has been utilized in proving the origin of certain 
urticarial eruptions, those due for instance to pork or mussels. 

The term anti-anaphylaxis denotes the process by which the 
outbreak of an anaphylactic shock or crisis is prevented. Credit 
is due to Besredka for having shown that the preliminary injection 
of small doses of the determining serum permits the injection of 
the total dose one hour later without disturbance. A very slowly 
administered injection is in itself anaphylactic to a certain degree. 
I have pointed out that a rational attempt has been made to treat 
urticaria by anti-anaphylaxis. This therapeutic method will per- 
haps find numerous and important applications in the future. 

That medicinal intolerance and anaphylaxis are not identical is 
apparent on the following grounds: In the first place, in spite of 
some contradictory experiments, it has not been established that 
non-colloid substances may produce an anaphylactic state. 
Furthermore, it is not uncommon for a toxiderma to manifest 
itself at the first use of a drug; in these cases, at any rate, there is 
nothing like the period of incubation which is required for the devel- 
opment of genuine anaphylaxis. Achard and Flandin were unable 
to produce in guinea-pigs either an active anaphylaxis with medic- 
inal agents or a passive anaphylaxis by injecting them with the 
serum of patients suffering from eruptions due to antipyrin, iodo- 
form, or quinine. Pending further research, medicinal intolerance 
must therefore be interpreted as a simple hypersensibility, not 
partaking of an anaphylactic character. 

It is necessary to point out, however, that Ch. Richet showed in 
1910 that animals which have been sensitized by an anaphylacto- 
genetic substance are to a certain degree sensitized at the same time 
toward all poisons even crystalloids. 

Looking at the question of idiosyncrasy from a wider perspec- 



462 ARTIFICIAL DERM AT in DBS 

tive, one may well ask with him if, just as human beings differ in 
their psychic personality, they are not each endowed with a humoral 
personality peculiar to the individual; the personal differences in 
the Immoral make-up, being due to heredity, ingesta, as well as the 
multiple intoxications and infections which they have experienced 
in the course of existence, accounting for the differences in the 
reactions toward injurious factors. 

2. PATHOGENIC MECHANISM— -It is not necessary for the 
pathogenic mechanism of the toxidermas to be uniform and always 
identical; it is not even probable that this is the case. 

The interpretation of external toxiderma is not difficult, the 
condition represents a sort of local chemical traumatism. It must 
be kept in mind, however, that in order to cause a reaction, the 
injurious substance must pass through the inert horny layer. The 
absorption of the normal skin is demonstrable only for volatile 
substances (ethereal oils, iodin, mercury, etc.), certain fatty sub- 
stances and the keratolytic substances (salicylic acid). It has 
been shown, however, that potassium iodide, antipyrin and some 
alkaloids may penetrate the skin under certain conditions. More- 
over, the slightest fissure of the horny layer constitutes a portal of 
entrance. 

Many substances give rise to eruptions when absorbed by the 
external as well as by the internal route; one is led to assume that 
the injurious action is exerted as an idiosyncrasy on the constit- 
uents of the skin itself. It is certainly amazing to see to what 
degree the cutaneous sensibility must be augmented for a reaction 
to occur with the infinitesimal quantity of substance carried by the 
blood stream to a given square centimeter of skin; but one is pre- 
pared to admit this hypersensibility in view of what has been 
established in the external toxidermas. 

It is very remarkable that this predisposition is often strictly 
localized and limited to a given territory which nothing seems to 
predetermine for this selection; the typical example of the anti- 
pyrinides, however, compels the recognition of this fact. 

It has been supposed that the vasomotor or trophic (?) nervous 
system, damaged by the circulating poison, might intervene in the 
localization of the internal toxidermas, a metameric distribution 
of which has sometimes been reported. But the inflammatory 
character of the great majority of toxidermic lesions renders the 
idea of a purely nervous pathogenic influence rather improbable. 

The role of the blood is indispensable in all not strictly local 
toxidermas; the injurious agent must be transported either to the 
nervous elements or to the skin. In a few exceptional cases, the 
blood medium is even morphologically altered; E. Hoffmann and 



TOXIDERMAS FROM EXTERNAL CAUSES 463 

others have noted eosinophilia in hydrargyria and Leredde has 
demonstrated it in iodism. 

The toxidermas were formerly very simply referred to elimina- 
tion, or to an attempted elimination of the toxic agent by the cuta- 
neous tissues. The purifying function thus attributed to the skin 
is now known to be in reality very limited, if not absent. It has 
not been demonstrated that in eruptions due to iodides or bromides, 
for instance, the altered skin contains a larger quantity of the 
metalloid than the neighboring skin. The positive findings of 
Adamkiewicz for iodin and of Gutman for bromin are offset by a 
mass of negative results; Pasini believes that in bromide eruptions 
the bromin exists in an organic combination not easily demonstrable. 
As to arsenic, it is known — and the fact has been confirmed by the 
careful analyses of Arm. Gautier — that the epidermis and its adnexa, 
hairs and nails, contain a proportion of the toxic agent relatively 
so high that the epidermic tissues must really be considered as 
normal routes of elimination of arsenic; but the condition exists 
both in the presence and absence of cutaneous lesions. 

In certain toxidermas, the part played by microbic infections, 
especially through pyococci, is very evident. Thus the iodide, 
bromide and tar acnes, the eruption due to thapsia, the miliaria alba 
following mercury and the application of plasters, contain staphylo- 
cocci with such regularity and abundance that the germs may be 
regarded as practically obligatory collaborators of the toxic agent. 

The eczematous and bullous toxidermas likewise open the door 
to the same agents which may lead to generalization and per- 
sistence of an originally toxic eruption, the transportation being 
facilitated by scratching. 

TOXIDERMAS FROM EXTERNAL CAUSES. 

This section comprises different groups of cases, according as the 
eruption results from: (A) Badly tolerated medicinal applications, 
external medicinal eruptions. (B) Application of counter-irritants 
or caustics, induced dermatitides. (C) Substances used by the 
patient in his work, occupational dermatitides. (D) Vegetable or 
animal poisons, dermatitides venenatce. (E) Applications made for 
the purpose of malingering, simulated dermatitides. 

The morphological appearances assumed by these various toxi- 
dermas have been sufficiently described in the first portion of 
this book. They belong especially to the following groups : eryth- 
emas, urticaria, eczema, pustules, bullae, ulcerations, gangrenes, 
dyschromias and folliculoses. 

A. External Medicinal Eruptions. — The therapeutic substances 
which are capable of producing lesions or reactions that the physi- 
cian had not expected, are innumerable. 



464 ARTIFICIAL DERM AT IT IDES 

W'nivr, either pure or containing anodyne products, employed in 
prolonged baths, in moist dressings, etc., macerates the epidermis, 
thereby predisposing to pyococcal infections. The phenomenon 
of the "crop" (poussee), so common in the majority of watering 
places, is to a large extent referable to the water. Poultices act in 
the same way, particularly when the linseed has become rancid 
and therefore irritating. Excessive washing with soap and alkaline 
or sulphur baths may cause dryness of the skin, redness, desquama- 
tion and the formation of vesicles. 

The majority of fatty or resinous substances which enter into the 
composition of plasters are capable, as a result of maceration, of 
irritating the epidermis and exciting eruptions accompanied by an 
abundant growth of pyococci. 

, I ntiseptics, even the weakest, such as boric acid, sodium biborate, 
etc., may prove irritative to the skin. Some remedies of this group 
are entitled to special mention. 

Pure carbolic acid is a caustic producing a white slough, almost 
without inflammatory reaction; strong or even weak improperly 
prepared solutions often give rise to carbolic acid erythema, some- 
times to vesicle formation with edema, carbolic acid eczema, and 
even to gangrene when employed in dressings, a fact which must 
not be overlooked (Chapter XV). 

Tincture of arnica, much liked by the laity for the dressing of 
contusions, has often a pronounced eczematizing action. 

Formol hardens the epidermis, which cracks and peels off, under 
simultaneous production of a dermatitis which may be necrotic. 

Salol, a compound of carbolic and salicylic acids, is like its com- 
ponents frequently the origin of persistent and progressive erythe- 
mato-vesicular dermatitis. As an admixture in tooth-washes or 
"catarrh powders," it gives rise to orbicular eczemas of the lips or 
nostrils which persist indefinitely when not traced to their real 
cause. 

Iodoform is especially to be dreaded in cases of idiosyncrasy. 
Following its application in even trifling amounts, the neighboring 
skin becomes deeply reddened and covered with small confluent 
vesicles. This dermatitis is accompanied by an erysipeloid or 
psendo-phlegmonous edema, especially on the face or on the geni- 
tals; it may even become generalized. The eruption terminates 
by desiccation or by suppuration; recovery takes place only after 
two or three weeks. It is certain that iodoform dermatitis 
results rather from the contact of the iodoform with the epidermis 
than with the cavity of an ulcer or a wound, or even with the 
surface of a mucous membrane. 

General symptoms, delirium and even death, have also been 
observed and are referable to the absorption of this remedy. 



TOXIDERMAS FROM EXTERNAL CAUSES 



465 



The substitutes for iodoform, iodol, aristol, europhen, airol, etc., 
are less frequently injurious. Orthoform may excite an erysipeloid 
and gangrenous dermatitis. 

Mercury and its salts, in external applications more often than 
after ingestion or injection, give rise in predisposed persons to 
eruptions known as cutaneous hydrargyria. It is true that the 
mechanical factor and the nature of the vehicle also play a role in 
mercurial inunctions; but the eruption frequently follows upon a 
simple application of blue ointment (Fig. 1T>) or dressings with 
sublimate, biniodide, cyanide, mercurial plaster and even applica- 
tions of calomel. 




Fig. 143. — Cutaneous hydrargyria of eight days' standing, occurring a few hours 
after inunction of the groins and the axillse with blue ointment for phthiriasis. 



The symptoms consist, in the first degree, of severe reddening 
with a burning or itching sensation, on which numerous miliary 
or submiliary vesico-pustules or small purpuric spots appear. This 
eruption, often localized in the groins, on the genital organs and 
in the axillse, sometimes tends to become diffuse and then gives the 
picture of cutaneous hydrargyria due to internal causes. A more 
30 



466 ARTIFICIAL DERMATITIDES 

or less dark and persistent pigmentation often follows the mercurial 
erythema. 

Reducing agents, so widely employed in dermatotherapy, are 
all in varying degrees capable of producing dermatitis; this is 
accounted for by their special chemical effect, sometimes favored 
by an idiosyncrasy of the patient. Sulphur, sulphites, resorcin and 
naphthol are usually not injurious unless employed in excessive 
dosage. Pyrogallol stains the epidermis black; it may produce 
erythema with enormous swelling and even sloughing. 

Chrysarobvn, when dissolved by the alkaline sweat, gives rise to 
a brown or purplish, more or less extensive reddening with pruritus 
and sometimes a pseudo-phlegmonous infiltration lasting several 
weeks. The bronzed erythema of chrysarobin is typical. When 
applied near the eyes, the remedy causes a severe conjunctivitis 
with swelling of the eyelids, ulcerations of the cornea, etc. 

The various tars, notably oil of cade may produce an ordinary 
erythemato-vesicular dermatitis. Their prolonged employment 
leads to hyperkeratosis. Some individuals moreover develop an 
eruption of folliculitis, solid papular elevations centered by a 
sort of brown comedo, with ultimate suppuration. This tar acne 
develops especially in hairy regions, particularly on the legs; it is 
obstinate and lasts several weeks (Fig. 123). 

Oxidizing agents are relatively slightly injurious. However, 
potassium permanganate in strong solution or as a powder, very 
strong hydrogen peroxide and other peroxides, alter the horny layer 
and cause redness and vesiculation. Picric acid, recommended 
as harmless, is capable of producing erythema with edema and 
eczematous vesiculation, even when employed strictly according to 
prescription. 

Dyes for the hair and beard usually have for their basis silver 
nitrate, subacetate of lead or pyrogallic acid; among their con- 
stituents, paraphenylene-diamin is especially dangerous. A few 
hours after the first application, or very often after a period of 
complete tolerance extending over months and years, an edematous 
and highly pruritic erythema suddenly makes its appearance on 
the upper part of the face and especially on the eyelids; rapidly 
extending to the entire face, the neck and sometimes the shoulders 
and the hands. If the reaction is severe, the erythema becomes 
covered with vesicles which rupture and are followed by oozing 
and crusts. The edema usually subsides in a few days, but the 
desquamation persists somewhat longer. An acute eczema of the 
regions indicated above, when the hair or beard has been arti- 
ficially colored, will be readily traced to its true cause. 

In order to prove that, a particular substance has been injurious, 
a trace of the suspected substance may be applied on a Aery small 



TOXIDERMAS FROM EXTERNAL CAUSES 467 

slightly abraded surface of the patient's skin and covered with 
gauze and a plaster; from twelve to twenty-four hours afterward 
an examination will disclose the presence or absence of a dermati- 
titis. This "reaction test" thus strictly localized is devoid of 
danger. 

The treatment of the external drug eruptions comprises in the 
first place the removal of the injurious substance, if traces of it 
persist. When possible, the employment of this substance and 
even of analogous products must thereafter be strictly avoided. 
Next, dressings appropriate to the degree and seat of the lesion 
may be applied, lotions, sprays, powders, soothing applications, 
as indicated in the treatment of erythemas, eczemas, etc. 

Internal treatment with calcium salts or ichthyol has sometimes 
seemed to be of some value in my experience. 

B. Induced Dermatitides. — In this paragraph will be considered 
the cutaneous irritations and lesions produced intentionally or 
otherwise by the physician, for therapeutic purposes. Skin lesions 
voluntarily produced by the patient with a view to malingering 
will be discussed separately (§E). 

Everyone is familiar with the reactions caused by the customary 
counter-irritants, rubefacients and vesicants, such as: mustard 
plaster, hot water, chloroform, spirits of turpentine,, ammonia, 
ethyl and methyl chlorides, tincture of iodin, iodized and analogous 
cotton, cantharides plaster or tincture, etc. 

It is noteworthy that their application leaves in some individuals 
a very undesirable and persistent pigmentation; this excessive or 
prolonged action may cause sloughs, badly healing ulcers, etc., 
especially in children and persons with a delicate skin. Old iodin 
tincture contains hydriodic acid and becomes caustic. The vesico- 
pustules caused by thapsia, croton oil and tartrate of antimony 
are often followed by cicatrices, so that these substances should be 
employed very carefully. 

As soon as the epidermis is damaged there is an open avenue for 
pyococcic infections and all aseptic precautions must therefore be 
taken before employing a strong counter-irritant; moreover, clean 
dressings must be applied after it has done its work. 

Subcutaneous injections of camphorated oil sometimes and 
injections of paraffin for cosmetic purposes very frequently leave 
intradermic or hypodermic nodules which have been discussed 
elsewhere in this book (p. 276). 

C. Occupational Dermatitides. — These comprise a great variety 
of eruptions ranging from acute erythema, or lichenoid thickening 
of the skin with cracks, to the different degrees of burns. 

Eczema known as occupational eczema is especially common (Fig. 
144), and pyodermatitides, in the form of impetigo, folliculitis, 
lymphangitis, etc., occur. 



1 1 is 



ARTIFICIAL DERMATITIDES 



The seat of the occupational eruptions depends upon the region 
exposed to the injurious contacts. 

The lesions therefore begin preeminently on the hands, more 
particularly their dorsal surface or still more often in the inter- 
digital spaces; the nails in the prolonged forms are often worn, 
detached or grooved, fissured and dotted. Next, the wrists and 

forearms are invaded. The face 
and neck are affected primarily or 
secondarily. The covered parts, 
the scrotum, groins and axillae 
are damaged in those cases where 
the clothes are impregnated with 
irritating dust, gases or fluids. 

The course varies according to 
the cause, form and degree of the 
eruption as well as the individual 
conditions in a given case. Occu- 
pational eczemas may become per- 
manently established and recur 
incessantly, behaving as if the 
chemical traumatism had been 
only the determining cause of the 
onset of a diathetic eczema. 

What has been said about the 
drug-eruptions permits me to be 
brief in regard to the eruptions of 
workers with chemical products 
(quinin, etc.), photographers (al- 
kalies and reducing agents, amido- 
phenol, metol, etc.) and operating 
surgeons; in the latter, the fre- 
quent scrubbing and washingwith 
soap predispose to the injurious 
action of the various antiseptics. 
Washerwomen, cooks and dish- 

, . . washers usually have a smooth, 

lie 144.— Occupational eczema 01 ... . K .. .,, , 

washerwomen. sliming, red and parqueted pal- 

mar skin; the excessive employ- 
ment of potash soap, washing-soda and Javelle water, is here very 
apt to induce an artificial eczema with a topographical distribution 
on the hands and fingers, as stated above. 

Bricklayers and plasterers have in the same regions a thickened 
sometimes fissured epidermis and are subject to eczematization of 
the fingers, hands and wrists, with pyodermatitis and lymphangitis; 
the handling of the various cements seems to be the essential cause. 




TOXIDERMAS FROM EXTERNAL CAUSES 469 

Grocers handle a mass of irritative substances and sometimes 
present, especially in the cold season of the year, eczematiform or 
lichenoid lesions complicated by edema and fissures, which have 
been designated as 'grocers' itch"; this term is fairly characteristic 
for the seat and gross appearance of this eruption. 

Cabinet-makers, painters and workmen who use varnishes,, essen- 
tial oils, especially spirit of turpentine, are exposed to erythemato- 
vesicular and edematous eruptions bearing a close resemblance to 
acute eczema or dysidrosis as well as to chronic eczemas. 

Sugar-refiners, confectioners, etc., who are in constant contact 
with sugar, often suffer from impetigos, whitlows and pyodermati- 
tides. 

There is finally an entire series of occupations in which the 
utilized materials themselves or their products give rise to a more 
or less ordinary dermatitis tending to secondary infections. It 
suffices to mention in this connection : the acneiform folliculitis, due 
to tar, petroleum and paraffin; the pyodermatitis of curriers, 
tanners and knackers; the various eruptions of mechanics, chauf- 
feurs, etc., who are in contact with impure or rancid oils; the pruritus 
of bakers [bakers' itch], etc. 

More specific in their cause and manifestations, are the occu- 
pational eruptions of workers in Provence cane; 1 spinners and 
weavers of flax; dressers of hemp; sorters or binders of wool; washers 
of silkworm cocoons; workers with chlorin (chlorin acne); and 
gardeners (poisonous plants), etc. 

Pigeonneau, or rossignol 2 is an occupational disease of the hands 
in skin-dyers, which was carefully described by Brocq and Laubry. 
It is characterized by lenticular ulcerations, not very numerous as 
a rule, occupying the dorsal surface of the fingers or the hand; they 
are round or oval, covered with an adherent black imbedded crust; 
their border is raised and reddened; the ulceration is perpendicular 
and deep, with an irregular floor. The affection is very painful 
and heals rather slowly. 

Treatment. — When dealing with an occupational dermatitis, the 
first thing to be done is to cleanse the parts by means of local 
baths or moist detergent dressings; these should be more or less 
frequently renewed and continued throughout the acute stage. 
In other cases the skin is cleansed with benzin, c6ld cream or vase- 
lin. It is rarely necessary to resort to chemical neutralization or 
solvents, which are sometimes dangerous in themselves. Topical 
medication is governed as usual by the lesion (erythema, burn, 
eczematization or pyodermatitis) and not by the cause. 

General treatment and especially hygienic rules must not be 
neglected. 

1 [A reed used for thatch-roofs.] 

2 [Young pigeon and nightingale respectively; popular names for this dermatosis.] 



1,11 AkTlPlClAL DEllMATITIDKS 

The difficulty in regard to occupational eruptions consists in 
the prevention of recurrences. Often, by utilizing precautionary 

measures and cleanliness, with protection of the exposed regions 
and attention to hygiene, the patient can resume his occupation 
and avoid the trouble which threatens him more seriously after 
the first attack. Sometimes, when there is an evident, well- 
marked and persistent predisposition, a change of employment or 
occupation becomes imperative. It is readily appreciated that the 
physician may find himself in a difficult position in cases of this 
kind. 

D. Dermatitis Venenata. — Numerous indigenous or exotic 
'plants are capable of producing by contact, not only a transitory 
urticaria like that caused for instance by nettles, but prolonged 
eruptions, especially of an erythemato-vesicular or bullous type, 
with edema, severe itching and sometimes fever. 

The eruption appears soon after the contact; it may extend and 
become generalized. When the patient's occupation or the data 
furnished by him do not suggest the cause, one may mistake the 
etiology of the condition which may thereupon become obstinate 
and recurrent. A considerable number of seasonal eruptions of 
the hands and face are of plant origin; this must be kept in mind and 
inquiries in this direction must be made. 

Among the poisonous plants which are most frequently respons- 
ible mention may be made of: daphne mezereum, several euphor- 
bias, rhus toxicodendron (poison ivy) and several related species, 
primula obconica (primrose), and a few analogous hothouse plants, 
arnica montana, clematis, colchicum, scilla, thuya, some chrysan- 
themums, etc. 

There also occurs occupational eruptions of vegetable origin, due 
to flax, cinchona, vanilla, bitter orange, satin [and other kinds of 
hard] wood, etc. 

Many animals, of different species, not counting the parasites 
which will be discussed further on (Chapter XXIV) may give rise 
to eruptions through contact with them. Such are the medusa?, 
actinia, processional caterpillars [brown-tail moth], and a few others 
cantharides, etc. 

Others have a poisonous sting, notably scorpions and many of 
the hymenoptera — bees, wasps, hornets, bumble-bees, etc. On 
being stung by one of these insects, an extremely severe pain is 
immediately felt and is promptly followed by urticarial redness 
with considerable edema; finally a bullous or vesicular eruption 
may develop, on the same spot or at a distance. A sting on the 
tongue or pharynx has been known to cause death. But aside 
from cases of this kind, alarming symptoms are sometimes observed, 
cither on account of multiple stings or perhaps due to the effect of 



TOXIDERMAS FROM INTERNAL CAUSES 471 

direct penetration of the poison into a vein or to a special sus- 
ceptibility. The venom of the hymenoptera, studied by Phisalix 
and by Calmette, is analogous to the venom of serpents. It may 
cause vertigo, vomiting, respiratory disturbance, weak pulse, fever, 
cold sweats, syncope and convulsions. Usually the disturbance 
passes off in a few days. 

The treatment of eruptions due to contact with plants and animals 
consists in the removal of the cause and in dressing the lesions 
according to the type of eruption. 

Against the stings of venomous insects may be recommended 
strong salt water, dilute ammonia, a solution of permanganate and 
rubbing with various fresh herbs, especially with parsley. In the 
first place it must be ascertained if the sting has remained in the 
wound and if this is the case, it must be extracted. Calmette has 
obtained excellent results from applications of calcium hypochlorite 
1 to 60 or Javelle water 1 to 100. 

E. Simulated Dermatitides [Feigned Eruptions]. — These are 
observed among beggars, prisoners, soldiers and in hysterical 
individuals. Medicinal substances (see induced dermatitides), or 
poisonous plants, or sometimes burns, are especially utilized by 
malingerers for the purpose of producing eruptions intended to 
excite compassion, to avoid a tedious service, or to make the subject 
interesting. The procedure varies according to the intellectual 
standard of the individual and his opportunities for securing the 
necessary materials. 

The lesions extend from a simple discoloration of the epidermis 
to eczematoid, erysipeloid and pemphigoid eruptions and even 
sloughing. Their configuration, arrangement and course naturally 
defy a general description. It is often their bizarre appearance 
that attracts attention; their angular or geometrical forms are apt 
to betray their origin; sometimes a trace of the material which has 
been used is discovered. It should be kept in mind that sycosis 
is relatively easily induced. 

The seat of the lesions is always accessible to the hand of the 
patient. Inquiry and investigation frequently fail, the patient 
keeping up his denial in the face of the unmistakable evidence. 
Immovable occlusive dressings naturally suppress the pathological 
manifestations or cause them to shift their place. Unless the 
patient can be made to see the error of his ways and unless he con- 
sents to be cured, recurrences are apt to be indefinitely prolonged. 

TOXIDERMAS FROM INTERNAL CAUSES. 

These may be grouped under medicinal toxidermas, serum toxi- 
dermas, alimentary toxidermas and autotoxic eruptions. 



472 ARTIFICIAL DERMATITIDES 

A. Medicinal and Toxic Eruptions of Internal Origin.— It is 
impossible to make ;i complete list of all medicinal substances and 
poisons capable of producing eruptions. Some react rather fre- 
quently upon the skin; with others, tins accessory effect is excep- 
tional. 

It is not so much the mode of absorption, the dose or the im- 
purities in the remedy which must he held responsible as it is the 
idiosyncrasy of the subject. 

The form of the eruption varies not only with the substance but 
also with the individual. 

I shall restrict myself to a rapid enumeration of the ordinary 
eruptions and their most common causes and follow with a 
description of the more characteristic special eruptions. 

Erythema in patches, urticarial erythema and medicamentous 
roseola represent the most common eruptions. The eruption is 
situated on the trunk, on the face and on the inner surface of the 
limbs; it is more or less abundant and extensive; it is sometimes 
scaly and often very pruritic. It may be accompanied by enanthema, 
conjunctiva] congestion, erythematous angina, but not by laryngo- 
tracheo-bronchitis as in measles. Fever and diarrhea are rare. 

The eruption appears at a variable time, often very soon after 
absorption. It may develop in attacks or extend progressively; 
it attains its height in two or three days. It is not rare for the 
patches of a more or less urticarial erythema to spread after the 
fashion of an oil-spot while the center recovers or heals, resulting in 
marginate or circinate forms. In a few days, the eruption dis- 
appears without desquamation and without leaving maculae. 

Toxidermic erythemas are due especially to the following sub- 
stances: quinin, antipyrine, morphin, the balsams, terpene, chloral, 
iodides, bromides, digitalis, salicylic, boric and benzoic acids, 
antimony, arsenic, exalgine, etc. In a soldier who had been exposed 
to the action of asphyxiating gases, I observed a marginate erup- 
tion of urticarial erythema, recurring for over eight months. 

Scarlatinoid erythema is less common; it occupies especially the 
flanks, the great articular folds and may spread over the entire 
body, persist several days and be associated with a more or less 
marked and prolonged lamellar desquamation; the clinical picture 
Mill then be that of a primary acute erythroderma (Chapter VI). 
Recurrences arc not uncommon. This form is observed especially 
after the administration of mercurials, quinin, chloral, opium, mix 
vomica, belladonna, salicylic acid, ipecac, antipyrin, sulfonal, 
benzoates, etc. 

Urticaria fChapter II), as common as the erythemas with which 
it is often combined, may be caused by the balsams, quinin, mor- 
phin, hyoscyamus, antipyrin, arsenic, iodides, bromides, chloral, 
santonin, etc. 



TOXIDERMAS FROM INTERNAL CAUSES 4,'-', 

Purpura is less frequent. A list of drugs which may cause its 
appearance has already been given (Chapter III). 

Bullous eruptions sometimes result from the absorption of iodides, 
bromides, antipyrin, arsenic, quinin, salicylic acid, antimony 
aconite, etc. The appearance is that of a bullous erythema (Fig. 
146), hydroa, or sometimes Duhring's disease. 

The same substances may give rise to suppurative folliculitides, 
of acute or sluggish course. 

Strictly speaking, there is no eczema of internal medicinal origin; 
but an already present eczema may become aggravated by any one 
of the above-mentioned substances, notably by the iodides, arseni- 
cals, etc. In case of eczematosis, numerous medicinal agents, and 
also dietetic errors, etc., are capable of starting an attack. 

Pigmentary spots sometimes originate under the internal use of 
antipyrin, arsenic, blistering gases and perhaps still other substances. 

Gangrenes, in the form of gangrenous eruptions or gangrene of 
the extremities, have been observed after absorption of ergot of 
rye, carbon monoxide, antipyrin, arsenic, iodides and chloral. 

Thallium salts produce a total alopecia. 

Belladonna, morphin, cocain, nux vomica, aconite, etc., may 
cause pruritus without eruption. 

It is obvious that the cutaneous manifestations due to internal 
medicaments are varied and often not characteristic; the same 
drug may produce very different effects. A suspicion of a drug- 
eruption is created by its behavior, its sudden appearance, its poly- 
morphism, the absence of symptoms common in the diseases which 
it simulates and by its recurrence under similar conditions. An 
inquiry, which must sometimes be most minute and searching, will 
establish the correctness of the suspicion which has been aroused. 
Occasionally, if the patient wishes or consents, it is possible to 
make an experimental demonstration of the diagnosis by adminis- 
tering a small dose of the supposedly harmful drug. It has been 
said before (page 461) that it is not possible in these cases to 
establish a passive anaphylaxis in animals. 

The following eruptions are less common; their characters 
suffice to suggest their origin; some are actually almost specific. 

Balsamic Erythemas. — Copaiva, cubebs, santal and turpentine 
give rise to roseolar erythemas or erythematous patches, often 
urticarial and marginate, very pruritic, of a bright red color, 
occurring specially on the extensor surface of the large joints or on 
the upper part of the trunk, later on becoming more or less general- 
ized. Their frequency has greatly declined since the less common 
use of the balsams in the treatment of gonorrhea. 

Antipyrinides. — Antipyrin has already been mentioned among 
the substances capable of exciting various erythemas, urticaria, 



474 



ARTIFICIAL i)h:i;\i.\TiT[Di-:s 



purpura, etc. Very rarely, the eruption may simulate syphilitic 
roseola (A. Fournier), although it lias a slightly deeper shade of red 
and is less persistent. 

This remedy also produces persistenl erythemato-pigmented 
patches, which were carefully studied by Brocq and are practically 
pathognomonic. These patches, single or scanty at the first onset, 
more numerous when the medication is continued (Fig. 14")), are 
scattered irregularly and may he situated anywhere; they are 
round or oval, nummular or the size of the hand, dusky red, well 
outlined and slightly urticarial and cause a rather pronounced 
burning sensation. 





i 


* 1 


1 lit * * 


*1 

* 


1 




If 

It 



FlG. 145. — Antipyrinide. Remarkably profuse eruption of erythemato-pigmented 

spots. 



After a few days the redness subsides and a fine or lammelar 
desquamation ensues; but the brown or even black pigmentation 
persists and fades only in the course of time. When the patient 
takes more antipyrin, after several hours or even in twenty minutes, 
the same spots again become congested and simultaneously new 
spots may appear, in haphazard distribution, taking a similar course. 
They are easily diagnosed from their circumscribed pigmentary 
and their stationary character. 

Sometimes, a certain number of these spots or patches become 
the seat of bullcB or vesicles-. 



TOXIDERMAS FROM INTERNAL CAUSES 



475 



Cases of localized edema and fulminating gangrene due to anti- 
pyrin [and affecting the genitals particularly], have also been 
reported. Compounds containing antipyrin (such as "migrainin," 
etc.), of course, have the same effects. The erythemas produced by 
other analgesic and hypotonic agents are not so well known; fairly 
numerous but dissimilar observations have been recorded. 

Iodides. — Potassium iodide and all other iodides or iodin com- 
pounds may give rise to diffuse erythemas, urticaria, purpura, or 
even to gangrene. Nodosities due to the iodides, analogous to those 
of ervthema nodosum are likewise known to occur. 



Fig. 146. — Iododern 




im of the neck, occurring a day after taking a mixture 
containing potassium iodide. 



The most typical iodide or potassium-iodide eruption is iodide 
pemphigus, which has been mentioned before (p. 177) and would be 
better described, according to its appearance, as bullous (Fig. 146), 
ecthymatous, or fungoid iodide eruption. When the administration 
of the remedy is continued, the lesions become ulcero- vegetative, 
increase in size and often invade the mucous membranes; they are 
accompanied by general disturbances, diarrhea, albuminuria and 
cachexia and may cause actual mutilations or death itself. 

Iodide acne is very common and develops almost exclusively in 
kerotic individuals; it affects the same areas as acne vulgaris, 



176 ARTIFICIAL DERMATITIDES 

from which it differs only in the more inflammatory character and 
the greater size of the papulo-pustules, their dark red color and their 
deep induration. Sonic lesions may be distinctly anthracoid 
! iododerma tuberosum I. 

Bromides. The most specific eruptions are produced by potas- 
sium bromide, more frequently than by other bromin compounds 
usually after the large and prolonged doses prescribed, for instance, 
in epilepsy. 

Bromide acne is like iodide acne; the ecthymatous and fungoid 
bromide eruptions resemble iodide eruptions of the same type. 

Fungoid papulo-tubercular bromide eruptions are less common. 
but are pathognomonic (bromoderma tuberosum). It consists of a 
nummular or more extensive prominence, with a crusted mammil- 
lated or papillomatous surface, of a purplish red color and peculiarly 
soft quality, giving the sensation of wet velvet to the touch. The 
distinctly outlined patch is bordered by a margin of sub-epidermic 
suppuration; it enlarges by several millimeters daily and becomes 
confluent with neighboring lesions. The fungoid bromide eruptions 
occur chiefly on the face and especially the nose though often on 
the legs (most frequently in my experience] or the buttocks, but they 
may also be met with in other regions. 

Their softness and rapid course distinguish them from papillo- 
matous or fungoid tuberculosis, fungoid syphilides and pemphigus 
vegetans. Pasini interprets the cutaneous lesions as due to bromin 
liberated in the stomach under the influence of hypochlorhydria. 

Hydrargyria. — Mercury and all its compounds without exception, 
whether absorbed by the gastric route, inhaled in form of mercurial 
vapors, injected into the mucous cavities, veins or subcutaneous 
tissues, may occasion an attack of cutaneous hydrargyria; infinitely 
small doses sufficing in the presence of a special idiosyncrasy. 
Hydrargyria through external applications is relatively frequent; 
through ingestion or injection it is very rare in proportion to the 
large number of patients to whom mercury is administered. It is 
advisable, however, to keep this possibility in mind. 

Alley and Bazin have described three degrees of hydrargyria: 

In the benign forms the trouble is limited to a localized redness 
with a few small vesicles, especially in the groins and on the inner 
surface of the thighs. 

In the moderate form, there is a severe erythema occupying the 
large folds, the groins, the axillae as well as the palmar and plantar 
regions; the red surface, sometimes dotted with hemorrhagic points, 
becomes covered with an abundant crop of small vesicopustules 
resembling miliaria alba. There is an intolerable itching and burn- 
ing sensation; fever, digestive disturbances and albuminuria may 
be present. The crusts are followed by oozing, then by a more or 



TOXIDERMAS FROM INTERNAL CAUSES 477 

less persistent lamellar desquamation (see Fig. 143). The clinical 
picture may be exactly that of an acute or subacute primary erythro- 
derma; upon occurrence of this eruption, hydrargyria should 
always be suspected. 

The malignant form is accompanied by swelling of the face and 
the extremities, by large bullae, pyodermatitides, abscesses, adenitis, 
angina and gangrene and may lead to death. Desquamation occurs 
in large shreds. It is noteworthy that in cases of cutaneous hydrar- 
gyria, mercurial stomatitis, colitis, etc., are not infrequently absent. 

Arsenic. — Aside from the ulcerations of the skin and mucous 
membranes observed in occupational arsenic poisoning, the adminis- 
tration of arsenic as a remedy gives rise especially in the palmar and 
plantar regions, but also elsewhere, to erythemas, urticaria, purpura, 
bullae, etc. The frequency of zona in patients who take arsenic has 
been noted. Injections of the arsenobenzols are followed, in rare 
instances, by more or less generalized eruptions of erythematous 
spots; even scarlatiniform erythemas have been reported. 

Pigmentations, in spots or diffuse, as well as arsenical keratoses 
are more typical; I have seen the latter, associated with a dystrophic 
condition closely suggesting xeroderma pigmentosum or senile 
degeneration, give rise to multiple epitheliomas, the so-called arsenical 
cancer. 

Treatment. — In the presence of a medicinal toxiderma of any 
kind, the essential point is the discovery of the injurious substance 
and the avoidance of its use. When its employment is absolutely 
required [as with arsenobenzol in syphilis] it should only be after a 
long interval, beginning cautiously with small doses, and [if possible] 
varying the form and mode of administration of the remedial agent. 
Rest, a laxative, abundant drinks, especially milk mixed with 
Vichy or Vals water and large enemas, may prove useful. 

Some medicinal eruptions (bromides, arsenic, mercury) persist a 
really long time after the responsible medication has been stopped 
and one must be prepared for this. The employment of corrective 
compounds or of so-called antidotes is not to be recommended. 
The cutaneous lesions should be treated [symptomatically] accord- 
ing to the form of the eruption. Against the general symptoms of 
iodism, Milian has recently recommended adrenalin. 

B. Serum Eruptions. — The disturbances which have been 
observed since the therapeutic employment of antitoxic sera 
(antidiphtheritic, antitetanic, antimeningococcic sera) were first 
attributed to the antitoxins, but are now known to be due to the 
vehicle, usually horse serum and may be produced by any foreign 
serum. The contributions of Arthus and von Pirquet, the clinical 
studies of Marfan, Weil-Halle and Lemaire, among others, have 
helped to elucidate the relations existing between "serum sickness" 
and anaphylaxis, 



178 ARTIFICIAL DEItM ATI TIDES 

True scrum symptoms, namely those occurring after the first 
injection, arc rather rare, being observed in only 14 per cent, of the 
ease-, according to L. Martin. They may appear very soon, or more 
frequently after an incubation of ten to fifteen days and generally 
consist of urticaria or a marginate ephemeral erythema, preferably 
localized in the vicinity of the injection, or disseminated. 

When another injection of serum is administered a long time (at 
least fifteen days, but even several years) after the first, the onset of 
anaphylactic symptoms is frequently seen (in 50 per cent, of the 
cases), developing either immediately or after four or five hours or 
sometimes after two to ten days. 

The symptoms developing promptly consist of anxiety, dyspnea, 
weak pulse and vomiting; they are controlled by injections of 
adrenalin. 

The more delayed disturbances manifest themselves under two 
type-, which are often associated: 

1. A local reaction, an erysipeloid or pseudo-phlegmonous redness 
with glandular swelling, lasting from two to four days. Marfan calls 
this the " Arthus phenomenon." 

2. A general reaction, a more or less profuse eruption of urticaria, 
with swelling of the face, or a marginate erythema with extensive 
policy clic patches, accompanied by edema, sometimes by anemia, 
subieterus, purpura, general prostration, very painful arthralgias 
and a fever up to 38° or 39° C. [101°-102° F.], lasting twenty-four 
or forty-eight hours. These clinical symptoms are associated with 
somewhat variable hematological disturbances; leukopenia or 
leukocytosis, mononucleosis, presence of precipitins, sometimes of 
hemolysins, delayed coagulation, etc. 

In order to avoid as far as possible the necessity for repeated 
injections in the course of a disease which requires serotherapeutic 
treatment, it is advisable to employ the scrum freely and repeatedly 
within the first few days. But the fear of serum accidents should 
in no case cause the abandonment of a re-injection when this is 
demanded by the nature and course of the infection; this at least 
is the rule laid down by the most competent authorities. 

All efforts should be made to avoid and control these symptoms. 
The best precaution consists in administering the re-injection 
very slowly, carefully watching the patient. Except in extremely 
urgent cases, it is even preferable to employ successive injec- 
tions with small doses according to Besredka's method. Begin 
by slowly injecting 1 c.C. of serum under the skin; one hour later, 
inject 2 c.C.; finally, after another interval, the total amount of the 
dose is injected. Calcium chloride, in daily doses of 1 to .'! grams, 
also possesses, as shown by Netter, a distinct preventive action; it 
diminishes by three-fourths the number of eruption cases among 



TOXIDERMAS FROM INTERNAL CAUSES 479 

re-injected patients and has besides a curative value. Flandin, 
Martin and Darre, etc., have experimentally studied the serotherapy 
of serum symptoms endeavoring to produce an immunization by 
means of repeated injections of very minute doses, constituting a 
curative anti-anaphylaxis. Their results are inconstant. 

C. Alimentary Eruptions. — In the case of an eruption occurring 
after the ingestion of a given food or drink, it is often very difficult to 
ascertain how far the symptoms are referable to the real toxicity 
of the suspected substance, the idiosyncrasy of the patient, or the 
auto-intoxications revealed on this occasion. 

Any food or drink the ingestion of which is usually forbidden to 
persons suffering from urticaria, pruritus and eczema, for instance, 
may accidentally give rise to an acute eruption or increase a pre- 
existing dermatosis in predisposed individuals. (See Therapeutic 
notes, §12.) 

The following may be considered as toxic, that is injurious, for 
most people: spoiled meats or fish, especially pork; very high 
game; certain meat extracts; spoiled or diseased mussels; edible 
mushrooms which have begun to putrefy, etc. 

The eruption usually follows closely on the ingestion and lasts a 
very variable time. It consists of urticaria of all kinds, urticarial, 
scarlatinoid or polymorphous erythema, purpura and bullae. 

General disturbances, more or less pronounced or serious, are its 
usual accompaniments in the form of fever, vomiting, choleriform 
diarrhea and various nervous disturbances. 

The treatment must aim primarily at emptying the digestive 
tract through all means at our command. 

The patient must then be placed on a strict diet, or better a milk 
diet, for some time to come. The nervous symptoms are counter- 
acted by symptomatic treatment and the same applies also to the 
cutaneous manifestations. 

D. Autotoxic Eruptions. — Although these are not artificial erup- 
tions, they may be considered as toxidermas and accordingly may 
be discussed in this chapter. 

At the present day, a general description of the cutaneous mani- 
festations of arthritism would be out of date; although some authors 
try to substitute chronic auto-intoxication for the vague term 
diathesis implied in this concept, the so-called arthritides of Bazin 
are now only of historical interest. 

It is equally impracticable to draw a picture of the cutaneous 
manifestations of gout, uremia or urinary insufficiency, hepatic 
insufficiency, cholemia, the gastro-intestinal dyspepsias, etc.; an 
attempt of this kind would be blocked by too much that is unknown. 
In discussing the erythemas, urticarias, purpuras, eczemas, lichens, 
pruritus and prurigos, acnes, etc., what little is known of the relation 



180 ARTIFICIAL DERMATITIDES 

of these dermatoses to general nutritional disturbances lias been 
mentioned. I repeat that eczematosis of adult or aged individuals 
may not infrequently lead to the discovery of a still latent internal 
cancer, an existing pyelonephritis or nephritis, etc. 

It is only the eruptions of diabetics, the so-called "diabetides" 
of A. Fournier, that admit of a more or less general review. 

Diabetic Eruptions. These are of two kinds: Some might he 
considered as internal toxidermas, dependent solely on the altered 
organic environment; these include pruritus, chronic urticaria, 
eczema, purpura, gangrenes and xanthoma. Others require in 
addition the intervention of an external factor, such as the pyococcic 
infection in the case of impetigo, ecthyma, folliculitis, furuncles or 
carbuncle; irritation through the sugar in the urine, in the case of 
genital diabetides. The latter alone require discussion. They may 
constitute the first symptom to arouse attention and lead to the 
diagnosis of glycosuria. In the absence of the necessary cleanliness, 
especially in women, the sugar-containing urine on soiling the skin 
irritates the epidermis and creates an excellent culture-medium for 
the yeasts and the microbes of suppuration. These women will 
accordingly develop pruritus, chronic erythema, or an often very 
red, edematous and oozing eczema, with sharp sinuous outlines, 
marked by a raised horny border or a crop of pustules, with an 
acute, obstinate or relapsing course. This diabetic eczema of the 
vulva often extends to the thighs, the perineum, the groins and the 
abdomen. In diabetic men, the glans and especially the prepuce 
are often red, swollen, chapped and eroded; the preputial orifice 
finally presents a fibrous induration, with retraction and radiating 
fissures, or even with complete phimosis. These various lesions 
sometimes reveal the presence of diabetes mellitus. 

In both sexes the clinical picture may become complicated by 
erysipelas or gangrene. 

The treatment must aim at diminishing the glycosuria through 
diet, hygiene and if necessary by means of antipyrine or its ana- 
logues. Absolute cleanliness must be maintained; with frequent 
application of alkaline, weakly antiseptic or astringent lotions 
and bland powders. Painting with a 1 per cent, solution of silver 
nitrate is often useful. Circumcision should be avoided if it be 
possible, for it is not devoid of danger in these conditions. A " cure" 
at the Vichy [or other alkaline] springs is indicated. 



CHAPTER XXIV. 
NEURODERMATOSES; PRURITUS AND PRURIGO. 

Pruritus, or itching, is a peculiar sensation which induces scratch- 
ing; it is as incapable of definition as is a gustatory or a tactile 
sensation. It is irrelevant whether this sensation, in different cases, 
be compared to prickling, tickling, tingling, the crawling of an 
insect, etc.; the word itching includes all these varieties and is 
understood by everybody. 

The finer pathogenesis of pruritus is entirely obscure. In order to 
interpret the dissociations of sensibility observed in certain diseases, 
physiologists have been led to suspect the existence of special organs, 
nerves or nerve-terminals, for the different forms of sensibility, some 
of which manifest themselves only on the skin and on the neighbor- 
ing mucous membranes: touch, pressure, pain, heat and cold. It 
has been surmised that this may be true of pruritus also, but neither 
anatomy nor experimentation has confirmed this theory. 

In all probability this mode of sensation is dependent on the 
ordinary sensory nerves, although it has been attributed by Jacquet 
to the sympathetic nerves. 

Itching results in different cases either from a special property of 
the irritant: artificial pruritus ; or from cutaneous lesions of various 
kinds: secondary pruritus; or from a special tendency of the indi- 
vidual, sometimes occasioned by local factors: primary pruritus. 
Frequently several of these conditions exist in combination. 

The practically inevitable consequence of itching is scratching. 
When the latter leaves the skin intact or produces only very ordinary 
traumatic lesions, even when more or less complicated by secondary 
infections, the existing dermatosis is described as pruritus, adding 
to this term some qualification suggestive of the pathogenesis or 
clinical variety of the pruritus. However, when the scratching 
gives rise to certain special reactions in the skin (papules of stroph- 
ulus, of prurigo, or lichenization), the dermatosis receives the name 
of prurigo, of which also several varieties are recognized. 

The distinction between pruritus and prurigo rests accordingly, 
in my opinion, upon a morphological and directly demonstrable 
fact, namely the presence or absence of the peculiar papules which 
I have previously discussed (Chapter VII) or of lichenization. It is 
really of small importance, for it is not uncommon to find a pruritus 
becoming transformed into a prurigo after a certain time. 
31 



482 NEURODERMATOSES— PRURITUS AND PRURIGO 

Under the special name of neurodermatoses are grouped pruritus 
and the prurigos which are neither artificial nor secondary, in which 
the itching appears as if primary and essential; it is dependent on 
a nervous disturbance of unknown character directly causative of 
the cutaneous manifestations. 

Artificial Pruritus. — It is a matter of common knowledge that 
certain irritants of the skin possess pruritic properties in them- 
selves. The crawling on the skin or the bites of parasites such as 
lice, bed-bugs, fleas, itch mites, oxyuris, the stings of the hairs of 
mttles or of the processional caterpillar, the application of a large 
number of substances of vegetable, animal or chemical origin give 
rise to more or less itching in all individuals. 

It may therefore be stated, with llebra, that under these con- 
ditions, pruritus is physiological. 

Scratching in such cases may be really useful, being a defensive 
movement which may be reflex and sometimes unconscious, whose 
aim is the removal of the injurious agent. 

Uncleanliness or, on the contrary, the excessive use of soap, etc., 
may also be the cause of persistent itching. 

The severity and duration of artificial pruritus are governed by a 
personal coefficient; it varies with the age of the patient, his tem- 
perament, his physical and reactionary state, his hygienic habits and 
the possible existence of a faulty diathesis. It can be modified, 
moreover, by suggestion or autosuggestion; many people feel like 
scratching as soon as the conversation turns on lice or bugs. It 
may assume the proportions of an obsession, a neurosis or mania — 
a condition which is designated under the name of parasitophobia, 
acarophobia, or dermatophobia. Inversely, it is at least modified by 
habituation, intercurrent fibrile diseases, etc. 

Secondary Pruritus.— Many dermatoses of external or internal 
origin include pruritus among their usual or possible symptoms. 

When the pruritus accompanies or follows the eruption, the inter- 
pretation of the fact is relatively simple. 

It may, however, precede it. In such cases, the question arises 
if the pre-eruptive pruritus is the effect of not yet perceptible his- 
tological lesions, or if it is a concomitant or preliminary effect of the 
cause which is about to give rise to the eruption, or finally if it is not 
itself the cause of this eruption by the scratching which it causes; 
in other words, if it is not a primary pruritus. 

The solution of this question in the different cases which may 
present themselves, constitutes one of the principal difficulties of the 
pruritus and prurigo problem. 

There would be no advantage in dwelling at length on pruritus 
in the dermatoses; this symptom, with its peculiarities, has been 
pointed out in each skin affection separately. The most pruritic 



PRIMARY PRURITUS 483 

of these diseases are scabies, urticaria, eczema, certain medicinal 
eruptions, lichen planus, Duhring's disease, certain erythrodermas, 
some leukemias and mycosis fungoides. 

As the result of scratching in the pruritic dermatoses the lesions 
of lichenization may appear and one may speak therefore of secondary 
prurigo. 

On the contrary, many cutaneous affections practically never 
give rise to itching, notably the syphilides, psoriasis, lupus, leprosy, 
tumors, etc. 

PRIMARY PRURITUS. 

This designation is applied to pruritus which is not connected 
with an external and evident cause. The skin is healthy, but, 
nevertheless, there is itching, sometimes to an intolerable degree. 
Strictly speaking, this pruritus should not figure among the derma- 
toses; but although the seat of the disease is elsewhere, the derma- 
tologist's advice is invariably sought because the symptom resides 
in the skin. 

This primary pruritus may be diffuse and even generalized, or 
it may be localized; the fact must be emphasized from the start 
that an internal and general cause may manifest itself by a regional 
or partial disturbance. 

Pathogenesis. — The pathogenesis of primary pruritus, also known 
as essential pruritus or pruritus from internal causes, has long 
taxed the ingenuity of physicians. Anticipating the data of posi- 
tive knowledge, it has been assumed to depend sometimes on 
a systemic disorder through intoxication, auto-intoxication or 
nutritional disturbance: dyscratic pruritus; in other cases, on a 
nervous disturbance or even on a neurosis: nervous pruritus. 
The distinction between these two pathogenic mechanisms is some- 
times not easily made and rests, moreover, merely on hypotheses. 

Auto-intoxication actually seems to be involved in the pruritus 
of icterus, diabetes, uremia and dyspepsias, which have their coun- 
terparts in the toxic pruritus due to morphin, belladonna, caff em- 
poisoning, botulism, etc. However, in order to produce pruritus, 
the action of the poison must necessarily affect some part of the 
nervous system-, terminal or central; making use of a bold figure 
of speech, it has even been said that it is the convolutions of his 
brain which the patient scratches on the skin. Hence, although 
of toxic origin, this dyscratic pruritus would be nervous in its 
mechanism. 

On the other hand, it is an extremely obvious fact that a pruritus 
may result from a nervous perturbation, the proof is furnished by 
emotional pruritus, irritative pruritus, the pruritus of tabes, that of 
certain classified neuroses, such as neurasthenia, chorea, etc. 



484 NEURODERMATOSES— PRURITUS AND PRURIGO 

The statement has even been made that a pruritus not referable 
to an external cause or to an exogenic or endogenic toxic factor 
might be considered as an autonomous neurosis, an idea which is 
expressed in the term of neuroderma, introduced by Brocq. 

By Jacquet, who made a specialty of the study of the sensory 
disturbances of the skin, pruritus was interpreted merely as the 
exaggeration of the normal cutaneous sensations; in the physio- 
logical condition, the total sensations coming from the integument 
constitute a harmonious whole, which may be called euderma; 
when this balance is disturbed, for example, under the influence of 
cerebral strain, or the absorption of certain foods, pruritus makes 
its appearance. 

Etiology. — The causes of primary pruritus are infinitely variable 
and of different kinds. As general and predisposing causes may be 
mentioned the race, the geographical and social environment (J. C. 
White says that in the United States pruritus is a national disease; 
in European countries the Jews pay a heavy toll) ; a nervous or 
arthritic heredity, resulting from a bad hygiene of overnourished, 
gouty, diabetic, etc., progenitors; and the age of greatest activity, 
which is from twenty to forty years, in both sexes. 

The following conditions act as favoring or determining factors: 
Brain-fag, which is Aery common in large cities; worry; late hours; 
grief; venereal excesses; cold and heat, some forms being seasonal; 
Duhring described a pruritus hiemalis (winter pruritus) which is 
often a prurigo; Bazin reported a pruritus a colore in persons 
employed in the vicinity of fires; — and hygrometric and barometric 
variations, to which some pruritics are susceptible. 

To the same group of causes belong the following: Dietetic 
errors, overeating, abuse of meats, condiments, stimulating bever- 
ages, such as coffee, tea, alcoholic drinks, etc.; a bad condition of 
the teeth and gums, also habitual constipation, which act as intoxi- 
cations; and the employment of certain remedies which cause a 
toxic pruritus, for example, belladonna, caffein, arsenic, morphin, 
opium, cocain, etc. 

Diathetic or dyscratic pruritus is often referable to auto-intoxi- 
cations, nutritional disturbances, functional disturbances or organic 
lesions of the viscera, the following being represented in this etiology : 
diabetes, gout, obesity, hepatism — with or without cholemia and 
often out of proportion to the degree of icterus, but perhaps related 
to the cholesterinemia, major and minor uremia, pyelonephritis, 
chronic enteritis, chronic appendicitis, circulatory disturbances, 
cancer, tuberculosis, the leukemias, etc. 

The nervous disturbances accompanied by pruritus are less 
frequently those of organic origin like hemiplegia, brain tumors, 
general paralysis and tabes (Milian) than those of functional 



PRIMARY PRURITUS 485 

character. Nervous pruritus is commonly observed among social 
failures, unhappy inventors, mental defectives, as the result of too 
much work or too much play and as the sequel of an emotional 
disturbance; the original depression is aggravated by the con- 
stantly recurring distress and by insomnia, leading to neurasthenia, 
melancholia and sometimes suicide. Formerly, cases of pruritus 
connected with pregnancy, menstrual disturbances, utero-ovarian, 
prostatic or vesical diseases, were interpreted as reflex pruritus, 
but these are now referred rather to auto-intoxications. 

Hematogenic pruritus is observed, although inconstantly, in the 
leukemias and may lead to the recognition of the blood disease. 

Determining causes are those which may excite a latent pruritus 
and bring on a crisis. The time of disrobing at night is very com- 
monly dreaded by pruritic patients, as it becomes the occasion of 
a real paroxysm; it is impossible to say if the exposure to cold, 
contact with the air or decompression are responsible; at any rate, 
many healthy persons scratch when disrobing, notably the majority 
of women after having removed their corsets, belts or garters. 

The attacks may also be brought on by a bath, rapid walking, 
cold or heat, even by a perfectly harmless meal. Certain persons 
are attacked by pruritus immediately after the ingestion of some 
food or drink, before any actual absorption can have taken place 
as if under the effect of a reflex; as particularly harmful in this 
respect are mentioned acid fruits, mussels and shellfish, cheeses, 
spices, alcoholic beverages, tea, coffee, etc. 

Often, however, the attacks occur spontaneously, even during 
sleep, apparently resulting from a nervous discharge. 

A few general data, well elucidated by Jacquet, dominate the 
etiology of pruritus: 

1. Predisposing and determining causes, internal and external, 
are often associated and act through a cumulative effect constitut- 
ing the prurigenetic summation. 

2. A preceding pruritus invites another; apparently each organic 
cell stores up more or less the stimulation which it has undergone, 
through a kind of local memory; this is prurigenetic mnemoderma. 

3. The accumulated sensory energy may become stationary or 
it may, on the contrary, become transported and transformed, 
representing sensory metastasis. 

Symptoms. — Pruritus, being an essentially subjective phenome- 
non, manifests itself only by scratching. Just as there are all 
possible degrees of itching, from a slight distress, which is easily 
forgotten, to an imperious, inexorable necessity, against which no 
provision holds out, so there are likewise all sorts and forms of 
scratching. An insignificant pruritus yields to simple rubbing with 
the finger-tip; a severe attack requires forcible scratching with the 



486 NEURODERMA TOSES— PRURITUS AND PRURIGO 

nails <>r rubbing with a rough towel, a brush or some other instru- 
ment which the patient uses as a curry-comb; sometimes a cold or 
hot application may accomplish the same object. 

No relation, however, can be established between the severity 
of the pruritus and the scratching, which is modified by individual 
factors or conditions inherent to the disease. 

Whoever has witnessed a characteristic pruritic crisis will retain 
a lasting impression. At the onset, the patient endeavors to con- 
trol himself; gradually he yields to the need of scratching, which 
incessantly increases, its satisfaction being accompanied by a 
truly voluptuous sensation; all restraint is promptly lost; pale, 
anxious, distracted by his trouble, the patient furiously excoriates 
himself, mutilating his skin and literally torturing himself, as if 
in the power of a blind force. Sometimes it is not until the skin 
is raw and streams with blood that relaxation occurs, satisfaction 
is obtained and the attack is over. The patient remains exhausted 
and as if ashamed of himself. Comparison with an epileptic attack 
and that involved in the term of "cutaneous masturbation" is 
entirely justified. 

It is impossible to say why scratching, even when carried to such 
an excess, produces relief; but all pruritic patients declare that the 
burning pain of the excoriations is preferable to the annoyance of 
the itching. 

The attacks usually last from five to fifteen minutes, sometimes 
an hour or longer; there is no rule as to their frequency and the 
rhythm of their recurrence. 

The pruritus described above may be diffuse and even general- 
ized; it is more frequently partial, regional, localized on a more or 
less extensive portion of the integument. But a diffuse pruritus 
sometimes tends to become localized after a certain time or.inversely, 
a regional pruritus may be seen later on to radiate and become 
diffuse. 

It is a noteworthy fact that a localized pruritus, originating under 
the influence of a local cause, may recur in situ on the occasion of 
an internal or general cause, through the effort of the mnemoderma 
referred to above; in this way an anal pruritus, for instance, caused 
by oxyuris or hemorrhoids, w r ill recur at the time of dietetic errors 
or overexertion. 

The consequences of scratching are partly immediate and partly 
remote. The traumatism produces in the first place congestion, 
with local heat and more or less interstitial exudation, that is, 
simple or urticarial erythema. 

I believe that by itself alone it may also excite an eczematous 
reaction, traumatic eczema (Chapter IV). 



PRIMARY PRURITUS 1X7 

More forcible scratching causes linear excoriations, usually 
directed in the course of the nails, which suggests their origin in 
spite of denial on the patient's part. Often the excoriations are 
punctiform and occupy follicular prominences, because from the 
beginning of the irritation the congested follicles have been raised by 
a spasm of their erector muscles and have projected above the gen- 
eral level. These excoriated follicular papules, covered with a bloody 
or serous crust, must not be confused with the papules of prurigo. 

The remote effects of scratching are in part of a special kind, 
consisting of papulation or lichenization and suffice to place a given 
case of pruritus in the group of the prurigos. 

Others are of an ordinary kind, namely secondary infection by 
pyococci, through the avenue of the traumatism giving rise to the 
most varied pyodermatitides. Even in the absence of suppura- 
tion, chronic scratching causes hypertrophy of the concatenated 
glands. Pigmentation, more or less diffuse, is likewise common. 
The worn-off nails which become polished and shining, have been 
mentioned elsewhere (Fig. 138). 

It will be seen, with Jadassohn, that from the standpoint of the 
effects of scratching, the pruritic diseases may be divided into 
two classes: in the first, the patient's nails tear off everything that 
protrudes and even dig into the epidermis to tear off shreds of 
tissue; this biopsic pruritus, as it was called by Besnier, is observed 
in scabies, pediculosis, sometimes in diabetes, Duhring's disease 
and the prurigo of Hebra. Pyodermatitides are commonly present 
in these cases. 

The second form of pruritus, although sufficient to cause insom- 
nia, is relieved by friction, pressure, etc., and is unaccompanied by 
any traces of scratching. Senile pruritus, the pruritus of lichen 
planus, of some types of icterus, of urticaria and of phthiriasis, belong 
to this group. The reasons for this difference are unknown. 

Clinical Forms. — It is not easy to formulate a picture of the 
forms of pruritus according to their origin. The following general 
remarks may be made on this subject. 

Dyscratic pruritus, that of diabetes and icterus in particular, 
is often generalized, is observed in relatively aged individuals, is 
especially nocturnal and gives rise to deep multiple excoriations. 

Nervous pruritus, or neuroderma of Brocq, attacks youthful or 
adult persons, is often regional or partial, occupying for example 
the large articular folds, the external aspect of the limbs, etc. It 
has a marked tendency to lichenization and consequently to prurigo 
vulgaris. 

Hematogenous pruritus is accompanied by a change in the blood 
(leukemias and anemias), easily recognized when kept in mind and 
looked for. 



488 NEURODERMATOSES— PRURITUS AND PRURIGO 

Senile pruritus, described'hyVWillan, formerly covered almost all 
the forms of pruritus of aged individuals. At the present time 
this name is restricted to a chronic, almost invariably generalized, 
remittent pruritus, in which the skin is flabby, dry, rough or smooth, 
more or less senile, but very resistant to scratching. As a matter 
of fact, even in severe senile pruritus, neither excoriations, nor 
urticaria, nor papules, nor lichenization are noted. This form is 
very rebellious to treatment. 

Localized pruritus is provoked by and depends upon either a 
local or a general cause. A general prurigenetic cause often 
localizes its effects in a region which has first been irritated in some 
way or takes advantage of an ordinary local lesion, such as varicose 
veins or metritis, to lodge in its vicinity. The interest in this 
localized pruritus is derived from the existence of these predisposing 
conditions which it reveals and which can often be remedied. Not 
infrequently it becomes eczematized, thereby leading to confusion 
with the pruriginous eczemas, or it may also develop into prurigo. 

Anal pruritus, which is perhaps the most common variety, at any 
rate one of the most obstinate and demoralizing forms, is often 
connected with the presence of oxyuris, lumbricoides, hemorrhoids, 
fissures, or with habitual constipation. 

Perigenital pruritus, sometimes associated with the preceding, is 
frequently related to diabetes, cystitis, diseases of the prostate, 
gonorrhea, or strictures of the urethra. Vulvar pruritus is suggestive 
of leukorrhea, diseases of the vagina, uterus and adnexa; it is not 
uncommon at the menopause or after spaying. It may create the 
suspicion of or excite masturbation. 

Nasal and peribuccal pruritus is often caused by' coryza, rhino- 
pharyngeal lesions, dental caries, neglected inflamed gums, or 
badly fitting artificial dentures. Buccal pruritus may occupy the 
lips, the cheeks, as well as the tongue; it is often associated with 
the neuralgia known as glossodynia. 

Pruritus of the hairy regions is usually symptomatic of parasites 
or of kerosis, pityriasis, etc. 

Palmar and plantar pruritus, described by Alibert and Hebra, is 
always symmetrical. It is rare and is encountered in unbalanced 
and toxic persons. It often assumes the form of burning sensations 
with nocturnal paroxysms. There is no trace of scratching. It 
must be distinguished from dysidrosis and from eczema. 

PRURIGO. 

I employ the term prurigo to indicate that group of pruritic 
affections in which the itching, which is the primary phenomenon, 
becomes associated under the influence of scratching with special 



PRURIGO 489 

cutaneous reactions, in the form of lichenization and prurigo 
papules. 

This definition, which is not given by all authors, is justified by 
the historical development of this question and meets with the 
nosographical requirements. 

Willan grouped prurigo under his heading of papules, which 
comprised: (1) strophulus; (2) lichen; (3) prurigo. Credit is due 
to Cazenave and Canuet for recognizing that in prurigo the itching 
is primary and the papule secondary. The elder Hebra again 
reverted to the idea that prurigo is characterized by a primary 
papule, a view which has since been refuted. Modern investiga- 
tions, especially those of Brocq and Jacquet, have established the 
almost universally accepted fact that the papules of prurigo and 
lichenization are secondary to the pruritus and due to the 
scratching. 

Accepting the above definition (prurigo = primary pruritus + 
special papules or lichenization), the diagnosis of the prurigos 
becomes easy and the relations which they bear to associated 
dermatoses are readily understood. 

In 'pruritus, there may be traumatic lesions from scratching, 
pyodermatitides and artificial eczema, but there are neither lichen- 
ization nor prurigo papules. 

Urticaria is a syndrome in which pruritus and scratching are 
accompanied by the rapid appearance of very ephemeral urticarial 
papules. In some forms of prurigo the skin is seen to react in 
the form of urticaria, especially at the onset; the etiology of the 
chronic urticarias coincides in its general outlines with that of 
pruritus and the prurigos; we must therefore admit the existence of 
a certain kinship between these two groups of dermatoses. 

Eczema, irrespective of its cause, may assume a lichenoid appear- 
ance and become extremely pruriginous. On the other hand, the 
prurigos frequently become eczematized. It is readily understood 
that the differential diagnosis between these two groups of cases, 
lichenoid eczema and eczematized prurigo, resting as it does merely 
on the priority of the pruritus or the eruption and on the more or 
less diffused lichenoid state, often presents almost insurmountable 
difficulties. 

Several other pruritic dermatoses may ultimately become 
associated with lichenization. The existence of secondary prurigos 
may accordingly be admitted, as well as the more frequent occur- 
rence of secondary pruritus. 

Symptoms. — It is not necessary to repeat what has been said 
about primary pruritus, its etiology, its pathogenesis and its clinical 
manifestations. 

The papules of strophulus and of prurigo have been already 



I'.HI 



VEURODERMA TOSES—PRURITt 's AXD PRtJRlCfd 



described (p. 1 10). All that remains to be discussed in this con- 
nection is lichenization. 

Lichenization (Besnier), which Mas first fully described by Brocq 
under the name of lichenification, is a chronic more or less persist- 
ent change in the appearance and the structure of the integument 
(Fig. 147). The lichenized skin is thickened as a whole; it may be 
described as striated, wrinkled, leathery, without either of these 
words conveying an exact idea of the condition. Its peculiar 
appearance is really characterized as an exaggeration of the fine 




Fig. 147. — Lichenization of the skin of the internal aspect of the thigh, in a case of 
prurigo vulgaris, in a woman aged forty years. 



striae which normally traverse it, which results in a criss-cross net- 
work with fairly regular meshes, more or less wide or narrow accord- 
ing to the region affected, resembling the cross-hatching of an 
engraving. The meshes are square, lozenge-shaped, or polygonal; 
they have a flat surface and usually present the appearance of 
smooth shining facets, like mosaic work. Sometimes they are 
covered with fine scales. 

The lichenized skin is less supple than the normal skin; its color 
is normal, or more often of a grayish or brownish hue; sometimes 
it is hypochromic. 



PRURIGO 491 

Its histological structure is less altered than one might be led 
to believe; the lesions consist of acanthosis, with elongation of the 
papillae and moderate infiltration of the papillary body. 

The lichenization occupies surfaces of very variable extent, in 
patches or areas, with diffuse borders, where there is a gradual 
transition to a normal appearance. [It is characteristic of the 
border that it is not limited by curved lines but is made up rather 
of short rectilinear elements.] On these borders, or on a surface in 
course of lichenization, only a few shining polygonal facets are 
noted, appearing very slightly papular; but not indurated. 

Lichenization must be distinguished from: the patches of 
lichen planus (Fig. 33) which are made up by the confluence of 
genuine planus papules and surrounded by typical papules; and 
from the lichenoid condition sometimes assumed by eczemas, 
eczematides and psoriasis; this is characterized by thickening and 
accentuation of the folds and furrows, but it is red, without shining 
facets and distinctly circumscribed at its borders. The striated 
and roughened condition sometimes presented by the skin of the 
genitocrural regions in gonorrheic women, a condition described 
by Brocq and L. Bernard, very closely resembles lichenization, 
although the surface according to these writers, is more villous and 
velvety. 

Lichenization may be primary and pure, that is, it develops on 
a previously healthy skin under the influence of rubbing and scratch- 
ing caused by pruritus; under this form it is the principal and 
most characteristic lesion of diffuse prurigo vulgaris; or it may be 
associated with the above-mentioned dermatoses, lichen, eczema, 
eczematides, etc. 

Since lichenization is a peculiar reaction of the skin under the 
influence of repeated traumatisms, the question may arise why does 
it not develop on all surfaces exposed to friction, or in all pruritic 
persons who scratch themselves. I shall restrict myself to giving 
the explanations offered by Brocq, who says that some cutaneous 
affections modify the vitality or the nutrition of the tissues in such 
a way that lichenification occurs with the greatest facility, whereas 
in other pruritic affections the resistance of the tissues seems to 
be normal or even increased; moreover, some individuals are 
especially predisposed to react in one or another way. [It must be 
admitted that this explanation explains nothing; it simply restates 
the facts.] The same theories are applicable to the pathogenesis 
of prurigo papules. 

As to the papules of strophulus, the question of their being of 
primary origin or secondary to the scratching, remains doubtful; 
it seems to me that they are often encountered at points of the skin 
which the patient can in no way injure or scratch. 



402 NEURODERMATOSES— PRURITUS AND PRURIGO 

Clinical Forms. — The prurigos constitute a continuous scries of 
morbid types, extending from eases related to urticaria to formi- 
dable dermatoses such as prurigo ferox. It would be desirable to 
classify them into varieties and this has been attempted by many 
dermatologists, who always emphasized those types which they 
had been best enabled to study. Hence the subdivisions of some 
do not agree with those of others and it is very difficult to find one's 
way. Without aiming at completeness, I shall limit myself to 
describing three principal forms: 

Acute Prurigo Simplex or Strophulus. — The affection named 
strophulus by Willan and Bateman and acute lichen simplex by 
Vidal, was given by Brocq the excellent name of prurigo simplex 
acutus, a name which has been received with general favor; abroad 
the terms of urticaria papulosa and lichen urticatus are often 
employed. 

The condition is an acute benign prurigo, characterized by a 
special and exclusive lesion, the strophulus papule, generally origi- 
nating upon an urticarial base; an eruption advancing in rapid, 
successive or overlapping crops, scattered over the entire body; the 
usual absence of lichenization and eczematization; a limited dura- 
tion, of a few weeks to a few months, but with possible relapses; 
and on the whole a favorable prognosis. 

Etiology. — Strophulus is of extreme frequency in early childhood ; 
later in life it is observed much more rarely, but is not unknown, 
however, in the period from fifteen to twenty-five years. 

A predisposition in certain families is obvious. It is encountered 
in apparently perfectly healthy children. However, two deter- 
mining etiological factors can often be recognized: (1) Overfeed- 
ing or underfeeding, digestive disturbances, gastro-intestinal fermen- 
tations, constipation, etc.; (2) the influence of teething, which is 
accompanied by nervous disturbances, excitement, insomnia and 
often also by digestive disturbances. 1 have elsewhere pointed out 
that the second period of life where strophulus is frequently met 
with corresponds to that of the eruption of the wisdom teeth. 

Symptoms. — Suddenly, in the midst of health, or sometimes 
after a slightly febrile general malaise, lasting one or several days, 
the eruption makes its appearance. It consists of urticarial 
spots surrounding and at first concealing the papule which has 
been previously described. Sometimes, a few urticarial elevations 
without papules are likewise noted and are easily brought on by 
scratching. 

This eruption is located anywhere, at the onset preferably on the 
upper extremities and on the trunk; later, on the lower limbs, on 
the neck and on the face; the palms and the soles are only rarely 
involved. 



PRURIGO 



493 



An eruption proceeds in crops of four or five, to about twenty 
lesions; it recurs every day, or every second or third day. The 
urticarial spot lasts only a few hours and then it fades, but the 
papule lasts from four to ten days. It is therefore not uncommon 
to see children covered with lesions of different ages (Fig. 148), 
some incipient, others at their acme or undergoing retrogression; 
and sometimes with not very persistent macules. 

Sometimes the lesions are small vesicles originating on an urticar- 
ial base; on the palms or the soles these vesicles may attain the size 
of a lentil. 




Fig. 148. — Profuse eruption of strophulus, or prurigo simplex acutus, in a boy 
aged six years. 



The course extends over a very variable period, from three 
weeks to three months; recurrences are common in little children; 
toward the age of three years the disease usually subsides. If it 
persists, there is danger of the development of Hebra's prurigo. 

Pruritus is variable and remittent, but often very severe. Some 
individuals scratch furiously and excoriate some of their papules; 
it seems, although this cannot be positively stated, as if the scratch- 
ing gave rise to new papules. Eczematization and pyodermatitis 
are rare. 

The diagnosis rests upon the demonstration of the typical papule, 
capped by a tiny lenticular yellow crust. In infants strophulus is 
often confused with urticaria, the stings of insects, sudoral and 
medicinal eruptions; in the young, with acne, papular erythema, 



494 NEURODERMATOSES— PRURITUS AXD PRURIGO 

acute disseminated eczema. Cases where the eruption is plainly 
vesicular may suggest varicella; it should be kept in mind that 
the lesions of the latter are less pruriginous [are most abundant on 
the back and frequent on the scalp] and do not spare the buccal 
mucosa. 

Prurigo simplex is evidently insufficiently known, for it is con- 
stantly being re-described by physicians under some arbitrary 
denomination. 

The treatment consists in correcting and regulating the diet; it is 
often advisable to diminish the quantity of milk and give a purga- 
tive or laxatives, among which calomel is most to be recommended 
for children. 

Locally, acidulated, carbolized or anodyne washes are preferable 
to baths, which are often not well borne. Zinc pastes with tumenol 
and tar and occlusion by well-applied bandages when possible, are 
effective against the itching. 

Hebra's Prurigo. — From the chaos of the pruriginous diseases, 
Ilebra picked out a morbid type which is designated under his name; 
a mild form {prurigo mitis) is known, as well as a grave and chronic 
form, characterized by a special course and by very polymorphous 
and severe lesions. It corresponds to the lichen agrius of the 
ancients and more or less accurately to the lichen polymorphe 
ferox of Yidal. 

As a rule the disease begins in the course of the first year of 
life, in the form of urticaria or strophulus, with severe, recurrent, 
very pruriginous attacks, but in many cases the pruritus comes on 
directly, without premonitory eruptions. 

At the end of a year or two, it reaches its fully developed stage 
and the clinical picture is characteristic: The child is tormented 
by incessant itching, or the pruritus may vary according to the 
season of the year. The skin is covered with linear or papulo- 
follicular excoriations, crusts, cicatrices, diffuse or regional eczema- 
tizations, pyodermatitides; it is thickened, coarse, pigmented and 
lichenized over large surfaces. The external aspects of the extremi- 
ties are chiefly affected, less often the trunk and sometimes the 
face; the large articular folds almost invariably escape. From 
time to time, more or less large prurigo papules are encountered, 
intermingled with the lichenization. 

In the least scratched regions, the skin has an earthy color and 
often resembles goose-flesh; the prominence of the follicles is attrib- 
uted to contraction of the erector muscles. The hairs, although 
abundant at first, soon become worn off and disappear. 

The lymphatic glands of the groins and axillae are always enlarged, 
and their enlargement is often very evident. Kosinophiles are 
usually present in large numbers in the blood and in the skin itself. 



PRURIGO 495 

The little patients are sickly, irritable, timid, their persistent 
sufferings and habitual insomnia accounting for their gloomy 
disposition. When they grow up, their infirmity condemns them 
to a solitary existence; they can share neither in amusements nor 
in attendance at school. 

The course of Hebra's prurigo is remittent; periods of relative 
calm are followed by aggravated attacks lasting several months. 
It is usually not until puberty or even about the age of twenty to 
twenty-five years that the disease subsides and becomes attenuated ; 
from this time on, without knowing the patient's history, one might 
mistake it for a chronic eczema or a prurigo vulgaris. The patho- 
logical manifestations vanish as a rule in mature life or old age, 
if the patient live long enough. 

In the etiology, the hereditary conditions mentioned above rank 
first in order, perhaps also to some extent errors in feeding in early 
childhood. Like other observers, I have several times noted the 
coincidence of Hebra's prurigo with asthma. [The possibility of 
sensitization to a particular article or kind of alimentary substance 
(e. g., milk, eggs) must be considered in the etiology.] 

Several varieties of this prurigo may be described : 

In the Hebra- Kaposi type, the cutaneous lesions increase in 
severity from the head to the legs. 

In what has been called the French type, they predominate on 
the face and the upper extremities, being on the contrary less well 
marked on the legs and on the trunk. 

Prurigo ferox (polymorphous lichen ferox of Yidal) is a rare 
type, characterized by prurigo papules scattered or grouped on the 
extremities (Fig. 149), the body and even the face; they are of 
considerable size, approaching the size of a cherry-pit or half a 
hazel-nut, often excoriated or vesicular at their apex. On the other 
hand, lichenization, while constant, is less pronounced. The itching 
is intense and the disease is extremely obstinate and of indefinite 
duration. 

[Prurigo nodularis (Hyde) is closely related to the above. All 
the cases described in America have developed in middle-aged 
women. The lesion, five to twenty-five in number, located almost 
exclusively on the extremities, are pea to hazel-nut in size, discrete, 
often capped by small vesicles, intensely pruritic and rebellious to 
treatment. The surrounding skin is normal in appearance.] 

Cases of Hebra's prurigo of late onset may possibly occur; some 
are of doubtful nature and liable to confusion with severe cases of 
prurigo vulgaris; others are not infrequently referable to the leu- 
kemias, especially to pseudo-leukemia with polynucleosis (prurigo 
lymphadenique of Dubreuilh). 



196 



NEURODERMATOSES PRURITUS AND PRURIGO 



Prurigo Vulgaris, ruder this name 1 designate the common 
form of prurigo, namely the group of cases which belong neither to 
simple pruritus nor to acute prurigo simplex nor to I [ebra's prurigo. 

A distinction is made l>et\\ een : I A diffuse or generalized form; 
it corresponds in a considerable number of cases to the diathetic 
prurigos of Besnier, to the diffuse neurodermatitis of Brocq, which 
he lias more recently designated a- "diffuse pruritus with licheni- 
fication." 2 A circumscribed form, corresponding to the circum- 
scribed lichen- of the older author-, to the chronic lichen -implex of 
Vidal, to the papular eczemas of Hebra and his school, to the 
dermatitis lichenoides pruriens of Xeisser, to the circumscribed 
neurodermatitis or circumscribed pruritus with lichenification of 
Brocq. 




I [g. 149 Prurigo ferox with large papules polymorphous lichen ferox of Vidal.) 



Prurigo vulgaris is characterized by primary pruritus; poly- 
morphous cutaneous lesions among which lichenization and eczema- 
tization predominate; and by a generally subacute remittent course. 

1. Prurigo Vulgaris Diffusa. Its etiology is that of the primary 
prurigos in general, hereditary factor-, neurasthenia, metabolic and 
nervous disturbances, abuse of coffee or alcohol, emotional causes, 
all of these play an obvious role, as well as the diathetic nutritional 
disturbances which are classified as "arthritism." 

It may begin in childhood, but especially between twenty and 
thirty years; it is less common after fifty. 

The affection appear- abruptly, often after an emotional shock, 
persisting for a few week-; then follow periods of subsidence and 
intermittent recurrences, sometimes of seasonal type. 



PRURIGO 497 

During the attacks the itching is continuous, with evening and 
irregularly periodical crises; the scratching may at first give rise 
to urticaria or erythema; but more or less rapidly, in different 
individuals, sometimes in a few days, it leads to the production of 
indistinctly outlined surface lichenizations, symmetrically occupy- 
ing the four extremities, the thorax and the flanks and sometimes 
the face, which becomes dull and grayish, with worn-off eyebrows. 
The combination of this diffuse lichenization with medium-sized 
and indistinct papules, with pigmentation, with traumatic eczema, 
excoriations and pyodermatitis, constitutes a picture characteristic 
because of its diversity (Fig. 150). 

The disease is of indefinite durations covering months or years; 
it may heal and is often replaced by asthma, hay fever, bronchitis, 
enteritis, etc. 




Fig. 150.— Diffuse prurigo vulgaris; right forearm of a young woman, aged twenty- 
three years, whose four extremities presented similar lesions; these lesions consist of 
diffuse lichenization, with pigmentation and numerous excoriated papules (diffuse 
neurodermatitis consisting of pure lichenization, Brocq). 

There are numerous varieties: Cases occur in which the prurigo 
follows upon a long period of simple pruritus; or an eczema may 
occupy the foreground, more or less concealing the other signs, so 
that many of these patients pass under the label of chronic eczema ; 
or the small and flat papules may lead to a confusion of prurigo 
with lichen planus; and finally, there are intermediate cases, with 
but few foci between the diffuse and the circumscribed form. 

Under the name of prurigo hiemalis, a variety of this prurigo 
described by Duhring is designated, more common in North 
America, especially in men, characterized by its evident relation 
to the cold season. The pruritus appears every fall, is more severe 
in cold weather and ceases in the spring. The first attacks fre- 
quently date back to childhood. The crises are vesperal and 
nocturnal, or may occur in the daytime under the action of heat, 
32 



498 NEURODERMATOSES— PRURITUS AND PRURIGO 

The most common site of the itching is on the legs, the thighs and 
sometimes the upper limbs. The condition is a simple pruritus 
in some persons, but in the majority of cases becomes a prurigo. 

J. Hutchinson has described a summer prurigo in every way 
comparable to the preceding. 

2. Prurigo Circumscripta or Lichen Simplex Chronicus of Vidal. — 
The etiology is the same as in the diffuse form; sometimes there 
exists a localizing cause, traumatism, internal lesion of the vicinity, 
etc. Circumscribed prurigo is more common in women. 

Its seats of election are the posterior portion of the neck, the 
upper part of the thighs, the neighborhood of the genital organs 
and the intergluteal fold, the external surface of the legs, the pop- 
liteal and axillary spaces, the elbows and the posterior aspect of 
the forearms; but it may occupy any area, including the palmar 
and plantar regions. The focus is single, or there may be two, 
three or more foci. 

At the onset, there is only intermittent itching, excited by 
occasional determining causes; next, it assumes the character of 
distinct, especially vesperal crises, lasting a few minutes, with 
furious scratching, followed by a voluptuous sensation of relaxation. 

More or less rapidly, the lesions of prurigo develop and in these 
cases present a typical appearance, in the form of a patch of chronic 
lichen simplex of French writers, the lichen of Vidal of foreign 
authors. It is generally oval, averaging the size of the hand; three 
zones can be distinguished in it: 

The external zone, 2 or 3 cm. wide, but imperfectly outlined, is 
brownish, quadrillated, barely thickened. In the middle zone 
appear lenticular and hemispherical prurigo papules, with an 
excoriated or shining surface grouped near the central zone. The 
latter is an infiltrated, hyperchromic or depigmented patch, lichen- 
ized to the highest degree, with a scaly or macerated epidermis 
according to the region and more or less distinctly outlined 
borders. 

Frequently the patches are not complete; the zones which repre- 
sent the successive stages of the change may be missing on one side, 
or altogether; the central disk may be replaced by more or less 
closely agminated papules. 

The duration of a circumscribed prurigo is from several months 
to one or two years, sometimes still longer. Recurrences are 
common. Sometimes, one or several new patches appear when the 
old ones have ceased to itch, become flattened and smoothed out; 
Inn the normal color is not restored until long afterward. 

The differentia] diagnosis must be made from lichen planus, 
lichen obtusus, the eczematides, the tubercular syphilides; it is 
usually easy, especially with the help of the anamnesis. In addi- 



PRURIGO 499 

tion to the rather common nerve or less marked pigmentary dis- 
turbances, or leukomelanoderma, cases of circumscribed prurigo 
occur in association with true vitiligo. 

Treatment of Pruritus and Prurigo. — Needless to say, before 
beginning the treatment of a pruritus or prurigo, the diagnosis of 
its form and probable cause must have been specified as closely as 
possible. 

In the first place artificial pruritus, of parasitic origin or due to 
external causes, must be eliminated; these require a parasiticide 
medication or special hygienic precautions; next, secondary pruritus, 
in which not only the symptom but the primary disease and its 
complications require treatment. 

In dealing with a primary pruritus or prurigo, its cause must be 
looked for among intoxications, hygienic errors, organic or func- 
tional anomalies; the urine and blood must be examined, etc.; it 
goes without saying that the treatment must take into considera- 
tion all the predisposing or determining factors which may have 
played a part. 

In a general way, the alimentary regimen must be as simple as 
possible, in the form of a milk- or lacto-vegetarian diet, at any 
rate free from all foods or drinks of a stimulating character or of 
difficult digestion; it is especially important to insist upon careful 
chewing, cleansing the teeth and keeping them in good condition, 
counteracting constipation, etc. [The possibility that the under- 
lying cause may be a sensitization to some article of food, often 
common like eggs or milk, must not be forgotten.] 

The inherent nervous element of every case of pruritus must be 
treated by general as well as local measures and psychotherapy 
may have to be utilized. 

Rest and a quiet mode of life are indispensable in overwrought 
or excited patients; the majority of sufferers from pruritus are 
benefited by a sojourn in the country, in the mountains or by the 
seaside. It has been observed that in the poorer classes, internment 
in a hospital usually brings about rapid improvement, whereas 
their discharge is followed by a prompt recurrence. Spinal punc- 
ture, as tried by Thibierge and Ravaut, is sometimes followed by 
a sudden and permanent improvement in these cases. The modern 
practice is to recommend various sero-therapeutic procedures, injec- 
tions of normal human serum, saline infusions, auto-hemotherapy, 
hypertonic sera with glucose or magnesium salts, etc., although the 
indications are not yet clearly established. 

Sedative medicinal agents, bromides, valerian, antipyrin and 
its analogues, carbolic acid, salicylates, etc., are of little value. 
Extract of guaco is very unreliable. As a rule, tonics are called 
for; cod-liver oil and arsenic, persistently administered, are often 



500 NEURODERMATOSES— PRURITUS AND PRURIGO 

very useful in Hebra's prurigo, in the neurodermatitides and the 
prurigo vulgaris of youthful debilitated patients. 

Among physical agents, baths are often not well tolerated, even 
with the addition of bran, starch, gelatin, lime blossoms, vinegar, 
etc. It is infinitely preferable to utilize general showers either 
lukewarm or barely warmer than the skin, applied with a very 
gentle spray almost without percussion ("dew-like douches"), for 
two, three or even four minutes or longer, repeated once daily or 
even twice daily at the start. 

Electricity, in the form of static baths, may soothe some cases of 
pruritus; high-frequency currents are even more useful. 

Watering-places suitable for patients with pruritus are, accord- 
ing to the desired end: Bourboule, Xeris, Laxeuil, Bagneres-de 
Bigorre, Saint Gervais, Loueche, Ragatz, etc.; sometimes, diuretic 
or strong sulphur springs are indicated. 

Local treatment is also of great importance. Aery hot rather 
than lukewarm washes should be recommended, with one of the 
antipruritic lotions indicated further on (Therapeutic Notes, sec- 
tion 4). Then it is essential' to protect the pruriginous surfaces 
from light and external irritants; this is accomplished by means of 
occlusive dressings or more conveniently through application of 
plasters, zinc gelatin or pastes, salves or varnishes, according to the 
extent of the pruriginous surfaces and the regions occupied by it. 

In the plasters and pastes, various tars may be advantageously 
incorporated, especially tumenol or vegetable tar, or antipruritic 
remedies such as menthol, phenol, camphor, various acids, etc. 
I Inguentum glycerinii with tartaric acid and pure cod-liver oil in 
inunctions or in salves or plasters, also possess a certain value. 

In circumscribed pruritus or prurigo two or three radiothera- 
peutic sessions (at a dose of 3 to 4 H every fortnight) are often 
strikingly successful, but their effect is not always very lasting; in 
case of repeated relapses, the applications must by no means be 
inconsiderately repeated, for fear of radiodermatitis. High-fre- 
quency currents act in a less brilliant fashion, but do not involve 
the same disadvantages; scarifications, filiform douches and douches 
of superheated air may be valuable adjuvants. 

The essential point is not to regard any of these therapeutic 
procedures as a panacea and as sufficient by itself, but to employ 
them separately or together, according to the case, devoting special 
care to the discovery and treatment of the individual conditions 
[the causative factor] in a given case. 

[I would particularly recommend the following plan of treat- 
ment for the old patches of lichen simplex chronicus: The patches 
are vigorously rubbed with a 10 per cent, solution of caustic potash 
till the surface begins to be denuded of epithelium and shows many 



PRURIGO 501 

oozing points. The burning sensation thereby produced is rather 
agreeable to the patient. The surface, washed with water and 
rapidly dried, is then painted with a solution of equal parts of 
ichthyol (or thigenol) and water and dusted thickly with an indif- 
ferent powder. The following day, treatment with the strong 
salicylic-acid-chrysarobin-tar ointment proposed by Dreuw is 
begun; an application is made night and morning for five days; 
then follows a period of four or five days during which the patient 
washes the affected area daily with soap and applies Lassar's paste. 
At the end of this period the discoloration produced by the Dreuw's 
ointment will have worn off and the patient is ready to begin the 
course again, starting once more with the caustic potash applica- 
tion, which should always be made by the physician himself. 

For the temporary relief of itching in all forms of prurigo, raying 
with ultraviolet light is of decided value.] 



CH AFTER XXV. 
PARASITIC DERMATOSES. 

Numerous parasites, animal or vegetable, may dwell on or in 
the human skin, giving rise to very polymorphous affections. 

The animal parasites, which are sometimes divided into epizoa 
and dermatozoa, comprise insects, acari and worms. 

The vegetable parasites or dermatophytes, with the exception of the 
schizomycetes or bacteria, belong for the most part to the class of 
niucedinia or filamentary fungi. Only the mucedini;e which vege- 
tate in the epidermis and its adnexa, the hairs and the nails, will 
be discussed in this chapter; the affections which they cause may 
be designated as epidermo-mycoses. As to the true dermato-mycoses, 
diseases due to dermatophytes growing in the corium, a special 
chapter will be devoted to their discussion (Chapter XXVIII). 

DERMATOSES CAUSED BY INSECTS. 

The parasitic insects of man live for the most part on the surface 
of the skin; they are epizoa. 

Pediculosis and Phthiriasis. — Under these names are designated 
the cutaneous lesions produced by lice. 

Lice are insects of the genus aptera and the family of pediculi. 
They have a pyriform head, provided with a sucking rostrum and 
mandibles which can seize the skin; a thorax bearing six feet ter- 
minating in a movable hook; and an abdomen not clearly sepa- 
rated from the thorax. The females, more numerous and somewhat 
larger than the males, lay a large number of eggs, with a chitinous 
envelope, which are designated as nits. When they hatch, the 
young resemble their parents and undergo no metamorphosis. 

Three kinds of lice are parasitic on man: 

Head-lice. — The head-louse, pedicuhts capitis, is about 2 mm. 
long, of a rather slender shape, a gray color marked with black 
spots on the border of the abdominal segments. It inhabits the 
scalp, especially in children of both sexes and in careless women 
and rarely the beard in men. In schools and asylums for pauper 
children, lice are endemic; in the seventeenth and eighteenth 
centuries, they flourished even at court in the heaped-up coiffures 
of the great ladies. 



DERMATOSES CAUSED BY INSECTS 503 

By their bites, lice cause severe itching, scratching and excoria- 
tions; but these symptoms may be altogether absent in some 
individuals. Without proper care, these lesions become infected 
and instead of simple crusted papules, impetigo, yellowish crusts 
adherent to the hair, folliculitis and abscesses of the scalp, pyo- 
dermatitis and adenitis at the nape of the neck and the lateral 
cervical regions, eczematization of the nape of the neck, the ears, 
the face, etc., may be seen. 

In a social environment of absolute neglect, the head of some 
individuals may be found to be covered as with a cap formed by 
matted hairs studded with innumerable nits, teeming with lice, 
matted together by infected crusts with a nauseating odor; the 
underlying scalp is bathed in pus. These extreme cases are desig- 
nated under the names of trichoma or plica. 

The deep follicular inflammations and abscesses may leave a 
patchy cicatricial alopecia, which is incurable. The glandular 
suppurations of the neck have been known to 
lead to anemia, cachexia and generalized infec- 
tions. 

The lesions of pediculosis of the scalp begin 
and predominate in the occipital region; a 
pruritus or impetigo localized at this point is 
suggestive of lice and these should be looked 
for, irrespective of the age or social standing 
of the patient. If they are not readily dis- 
covered on parting the hair, at least nits may 
be found appearing as white or grayish oval Fig. 151. — Pedicuius 
grains stuck fast to the hairs in more or less capitis— male. After 

° . , , , t Kuchenmeister. 

considerable number. 

Treatment. — In boys or men, the hairs should be clipped close 
to the head; in young women, the hair can almost always be spared. 

In those cases where the hair teems with lice, it is customary in 
the Saint Louis Hospital to begin the treatment with the application 
on the head during one night of a thick layer of vaselin covered with 
a bandage; the vaselin smothers and destroys the parasites. 

When the lice are not so abundant, dressings with camphorated 
alcohol left in place for a few hours, or washing with bichloride in 
vinegar (1 : 500), or applications of powdered stavesacre or pyre- 
thrum sometimes suffice to kill the lice and nits. To get rid of the 
latter, it is advantageous after untangling the hairs to employ 
a fine-toothed comb dipped in hot vinegar; the latter has the 
property of dissolving the cement which fastens the chitinous 
envelope of the nits to the hairs and of facilitating their removal. 
When there are many crusts, these should be softened with sprays 
or moist dressings, before removing them with soap and water; 




504 



PARASITIC DERMATOSES 



followed by the application of a sulphur, naphthol or salicylic acid 
ointment or balsam of Peru. 

Body-lice. — The body-louse or clothes-louse, pediculus corporis, 
sen rrsiiiut uli, is longer, measuring nearly 3 mm., of a yellowish 
white color and its abdomen has no black spots. It inhabits 
especially the clothing in contact with the skin, flannels, shirts and 
drawers; it is encountered among the poor, in tramps and in out- 
ca>t> neglectful of all personal cleanliness. Unlike the head louse, 
it attacks adults and old people rather than children. Lice have 
abounded in the trenches during the war. The parasites or nits 
are found especially in the folds, along the seams, where they are 
accumulated in severe cases of pediculosis as a dense mass of yel- 
lowish beady granules, stuck to the threads of the garment. They 
are also found, however, on the body hairs, 
notably at the pubis, in 90 per cent, of the 
cases (H. Bulliard, 1917). The clothes-louse 
is proverbially prolific; according to Leuwen- 
hoeck, two breeding females may in the 
course of two months produce 18,000 young 
lice. 

The bite of the body-louse gives rise to a 
highly pruritic urticarial papule. The itch- 
ing and scratching are especially severe in 
the evening and at night. A sort of habit- 
uation apparently becomes established in 
inveterately lousy subjects, there is no 
longer an eruption and the itching is not 
conscious, although the scratching persists 
instinctively, as shown by the linear excori- 
ations following the scratch of the nails. 
The shoulders and the upper portion of the back represent the site 
of election of this pediculosis, next the abdomen, the loins and the 
anterior aspect of the thighs. The face, the scalp and the feet and 
hands are exempt. The excoriations may become the starting-point 
of pyodermatitides. 

[Body-liee have been shown to be carriers of typhus and possibly 
also of "trench-fever."] 

A long-standing pediculosis leads to a rather peculiar modifi- 
fication of the skin, characterized by thickening, a dry and scaly 
epidermis and especially a dark pigmentation; from this background 
stand out the white cicatrices, recent excoriations and the innu- 
merable crusts. This melanoderma of pediculosis (p. 329) is most 
marked on the shoulders and the back, but may become generalized. 
The pigmentation may be observed even in the mouth, a proof that 
scratching does not sufficiently explain its genesis. 




Fig. 152. —Pediculus 
corporis — female. After 
Kuchenmeister. 



DERMATOSES CAUSED BY INSECTS 505 

A differential diagnosis in these cases must be made from Addi- 
son's disease, in which pigmentation of the mouth is usually present. 
But the topographical distribution of the Addisonian melanoderma 
is different and itching and evidences of scratching are absent. 

Asthenia and cachexia possess less diagnostic value, being, like- 
wise encountered in the chronic pediculosis of poverty-stricken 
subjects, which here assumes the appearance of a general disease, 
known as Vagabonds' disease. 

The differential diagnosis from the diathetic forms of pruritus 
must take into consideration the different localization of the itching, 
but is based especially upon the presence or absence of the parasites 
and their nits. 

The treatment consists in disinfection of the clothing in a steam 
sterilizer and in the necessary personal cleanliness. 

When no steam sterilizer is available, 
the garments may be pressed out with 
a hot iron or exposed to fumigations 
with cinnabar; these measures, com- 
bined with the persistent employment 
of insecticide powders, the wearing of 
clean linen and repeated washing with 
soap and water, followed by parasiti- 
cide inunctions (see Therapeutic Notes, 
section 10) may be sufficient. 

Pediculus Pubis. — Phthirius ingui- 
nalis, popularly known as the crab- 
louse, is nearly as broad as it is long, 
vaguely resembling a crab; it lives an FlG 153 ._p e dicuius pubis. 
the hairy regions of the pubis and After Schmarda. 

vicinity, where it clings to two neigh- 
boring hairs by means of the curved hooks of its feet. In hairy 
men, it may invade the thighs, the entire trunk and the beard; in 
both sexes it infests the axillae; in children and young women it 
may even lodge on the eyelids, causing a blepharitis phthiriasica. 

Crab-lice are usually acquired through sexual intercourse, but also 
through indirect contagion, in water-closets, or infested bedding in 
hotels. It has often been noted that this parasite is less common 
in the very lowest class where personal cleanliness is absent, than 
in the middle and even in the wealthy class. 

Pediculus pubis gives rise to a very variable amount of itching in 
different individuals and to scratching with its usual sequela?. 
This etiology must be kept in mind in considering an eczema or 
pyodermatitis of the regions mentioned. Together with the crab- 
lice, nits will be discovered sticking to the hairs near their base. 

A peculiar consequence of the bite of phthirius is the appearance 




506 PARASITIC DERMATOSES 

of blue spots or shaded spots [taches bleues, taches ombrees, macules 
ceruleoe], seen especially on the abdomen, the flanks and the thighs. 
Formerly regarded as symptomatic of undetermined or even of 
typhoid fever, these spots have been traced to their true cause by 
Falot, Mourson and the experiments of Duguet [though their 
pathogenesis is still unknown]. 

Treatment. — The classical treatment with inunctions of blue 
ointment — which should be rejected on account of the mercurial 
eruptions so frequently (and stomatitis occasionally] caused by this 
salve — is preferably replaced by inunctions with yellow precipitate 
ointment of 5 or 10 per cent., or a white precipitate or naphthol 
salve or balsam of Peru. Washing with bichloride-alcohol (1 : 500) 
is also effective. [A salve containing three parts of ammoniated 
mercury ointment and one part of blue ointment is safe and effective.] 
In phthiriasis of the eyelids, Jullien recommended the removal of 
the parasites one by one by means of a forceps. 

Other Sucking Insects. — Fleas. — These are of various kinds, 
each attacking a different animal. The human flea, pulex irritans, 
lays its eggs in the dust of floors, etc. Its bite produces a character- 
istic lesion; a hemorrhagic point surrounded by a lenticular zone of 
erythema; this disappears in a few hours, whereas the central ecchy- 
mosis persists several days. In children and in persons with an 
irritable sensitive skin, an urticarial wheal forms at the onset; 
[and in some cases, the wheal on subsiding leaves behind a papule 
which itches periodically for several days]. Some individuals are 
not attacked by fleas. In cases of extreme abundance of fleas, in 
rag-pickers for example, the entire skin may be dotted with minute 
red spots resembling purpura. 

Fleas may act as carriers of the germs of severe infectious diseases; 
there is reason to believe that these insects convey Bubonic plague 
from rats to man. 

Pulex Penetrans or Jigger. — This variety, Rynchoprion penetrans 
or Dermatophilus penetrans, occurs in tropical America and in 
Africa; the female burrows into the cutis, especially on the toes and 
soles of the feet, where it grows to the size of a pea, causing a 
furunculoid abscess. The loss of one or several toes, gangrene and 
tetanus, may be the consequence of this "dermatophilia." 

Bed-bugs. — The bed-bug, cimex lectularius, lives and multiplies 
in wooden bedsteads, in cracks of wainscoting and in upholstery. 
At night these animals sally forth from their hiding place and bite 
the sleeper, producing red urticarial elevations on the skin, some- 
times with extensive edematous swelling and a painful burning 
sensation. They are suspected of being possible carriers of Oriental 
boil, Bubonic plague, the trypanosomiases and Koch's bacillus. 



DERMATOSES CAUSED BY AC Alii 507 

Mosquitoes. — This name is applied to an entire series of species 
of culex, simulia, stegomya, anopheles, etc., distributed in all countries, 
especially hot countries. The female sting the parts accessible to 
them, especially at night, producing a rather persistent urticarial 
swelling, particularly after scratching. 

Great interest is, attached to these insects since it is known that 
their various kinds serve as intermediary hosts and transmitters 
for the parasites of malaria (anopheles), of yellow fever (stegomya), 
of filariasis and perhaps also of pellagra (simulides) and of leprosy. 
[The simulium theory of pellagra is no longer entertained.] Through 
the systematic destruction of mosquitoes immense tracts of land 
have been redeemed. 

The treatment of the bites of fleas, bed-bugs and mosquitoes 
consists in applications of alcoholic solutions of menthol or carbo- 
lized vinegar, dilute ammonia, collosol, naphthalan, etc., followed 
by bland powders. General prophylaxis, namely the destruction 
of the insects, often presents serious difficulties. Protection 
against mosquito bites is secured through the employment of 
mosquito-netting [or by rubbing the exposed parts of the skin 
with oil of citronella]; in a closed room, pyrethrum may be 
burned. 

DERMATOSES CAUSED BY ACARI (MITES). 

The parasitic acari of men are in part true dermatozoa, living in 
the horny epidermis, such as acari or sarcoptes, or in the pilo- 
sebaceous follicles, such as demodex; and in part epizoa, such as 
ticks, etc. 

Scabies. — Scabies is a contagious parasitic dermatosis, caused 
by an acarus, the Sarcoptes scabiei (Latreille), variety hominis 
(Megnin) . It is extremely pruritic and is characterized essentially 
by a special dermatological lesion, the burrow; and by polymorphous 
accessory eruptions, having a regional and symmetrical distribu- 
tion. 

The ancients, confusing scabies, psora or the itch, with the pruri- 
gos, interpreted it as a diathetic disease, subject to metastases, 
which was treated by venesection and blood purifiers. It was in 
vain that the parasite was pointed out by Mouffet (1634), C. 
Bonomo (1687), Wichmann (1786). The truth was not established 
until Renucci (1834), a student from Corsica, demonstrated in public 
in the clinics of Alibert, the sarcoptes which his countrywomen had 
taught him to know and extract (Fig. 154). 

Symptoms. — The itch is observed in all social strata and at any 
age; it is more common, however, among prostitutes and paupers 
living in crowded quarters. 



508 



PA RA SI TI C I) E R MA TOSES 



The symptoms do not appear until after a latent period, averaging 

ten days. 

The eruption is localized or predominates in certain areas of 
predilection, which should he systematically explored in all patients 




Fig. 154. — Sarcoptes scabiei, male and female. Reduced from Furstenberg, after 
Murray. 




Fig. 155.— Scabies. 



complaining of nocturnal itching. These are: the hands (Fig. 155), 
the interdigital spaces, the lateral aspects of the fingers, the wrists, 
more particularly their ulnar side, the elbows, the anterior wall of 



DERMATOSES CAUSED BY ACARI 



509 



the axilla, the ankles and the heels; in men, the sheath of the penis 
and the glans; in women, the breasts; in children, the buttocks. 
But the lesions may also occupy any other region, excepting the 
head which always escapes and the neck and back which are usually 
free. This topography in itself is characteristic. 

The itch, however, has a pathognomonic feature, the burrows. 
These are narrow grayish tracts, as if traced with the point of a 
needle, taking a curved or sinuous course which does not correspond 
to the folds of the epidermis. They have a length of 2 to 3 mm. or 
more; Dubreuilh observed a burrow 4 cm. long on the foot. These 
burrows represent the passages dug by the parasite in the horny 
ayer of the epidermis. They are often dotted with black points 
which indicate the exit orifices of the newly hatched larvse. Their 




Fig. 156.— Scabies burrow. The shred of horny epidermis containing this burrow 
was ablated with a razor; it is shown from its lower or deep aspect. A, entrance 
orifice; B, black matter, excreta; C, opening; D, ova; E, acarus. X 50. 



general color, which is darker in laborers and uncleanly persons, is 
partly referable to the excreta left by the sarcoptes and also to 
deposits of dust and dirt. White burrows may be found in the 
better classes. 

One of the extremities of the burrow, its head, is marked by a 
small nacreous elevation, the acarus eminence of Bazin; this is a 
tiny deep vesicle which forms in the vicinity of the sarcoptes. The 
animal may be extracted by tearing off the roof of the burrow with 
a needle and catching it in the cul-de-sac; or the entire burrow may 
be excised by means of fine curved scissors or a razor (Fig. 156). 
The burrows are most easily discovered on the fingers, the wrists, 
the elbows, the penis, the heels, in general where there is a thick 
epidermis, 



510 



I'. 1 /,'. 1 SI Til • DERMA TOSES 



The other lesions of scabies are accessory or secondary erup- 
tions, of variable characters and abundance. At the onset, these 
consist of spots of erythema or urticaria; next, of punctate or 
linear excoriations produced by scratching, crusted miliary papules, 
vesicles of dysidrotiform eczema, or ordinary eczema scattered or in 
patches (scabietic eczema); and finally, of various pyodermatitides 
—impetigo, folliculitis and ecthyma (scabietic ecthyma), suppu- 
rating or dried into crusts which are scattered by the scratching and 
may even be transported to the face. These lesions may become 
complicated by lymphangitis, adenitis and cellulitis. Eczema of the 
nipples and areolae in women ( Fig. 1 57 1 is always due either to scabies 
or to pregnancy. The polymorphism of the scabies eruptions is a 
characteristic feature, but their topographical distribution is even 
more so. 




The itching of scabies is usually almost intolerable. Its principal 
attribute is its nocturnal character; it is especially pronounced at 
the moment of retiring, but lasts until morning, often causing com- 
plete insomnia. This time is the period of activity for the acari. 
The itching is more or less localized or general. In some individuals, 
scratching is unconscious; they scratch and flay themselves without 
being aware of it. Pruritus may be absent although this is very rare. 
[A moderate degree of eosinophilia is commonly present in the 
blood of scabietics.] 

Etiology. — The fertilized female of Sarcoptes scabiei is alone re- 
sponsible for digging the burrows and causing the symptoms of 
scabies. It has the shape of a flattened oval and measures one-third 
or one-fourth of a millimeter; it is therefore visible to the nuked eye 
as an opaque whitish point. The anterior two pairs of its eight feet 
are furnished with cupping pads, the posterior two pairs with long 
bristles. The males, which do not inhabit the burrows, are much 
rarer and more difficult to discover; they are only half the size of 



DERMATOSES CAUSED BY ACARI 511 

the females and their fourth pair of feet also is furnished with cup- 
ping pads. 

The ova, which the female drops behind her in the burrow, meas- 
ure 0.16 mm. x 0.10 mm. and are more developed in proportion to 
their nearness to the entrance orifice. They hatch in four to eight 
days and the young leave the burrows through the openings to 
settle elsewhere. 

The sole cause of scabies is the transmission of the parasite. There 
exist neither individual immunity nor predisposition. In view of 
the habits of the sarcoptes, the contagion occurs almost exclusively 
at night. It is necessary for an impregnated female to pass from an 
infected to a healthy subject. This transmission is practically 
inevitable in persons who share the same bed, hence family epidemics 
and the frequent venereal origin of scabies. Contagion is possible 
through unchanged bed-sheets in hotels, through clothing, through 
sheets in sleeping-cars; it may very exceptionally result from con- 
tact in daytime; it is very doubtful if it can occur through tools, 
books, etc. 

[Scabies is one of the commoner skin diseases. In the statistics 
of American Dermatological Association it averaged about 5 per 
cent, of all cases during a period of thirty years. In the first 
decade of this century, however, there was a great increase in the 
incidence of the disease and in 1908 it constituted 10 per cent, of 
all skin diseases seen — a veritable epidemic. In general, scabies is 
somewhat more frequent in European countries than in America.] 

Prognosis. — Scabies never heals spontaneously. In some nervous 
individuals it may end in marasmus, on account of the pruritus 
and insomnia. Albuminuria is said to be not very rare in patients 
suffering from the itch; it is attributed either to the toxins of the 
sarcoptes or to nephritis caused by the microbes of suppuration. 

In certain villages of Norway, Brittany, Italy, scabies was 
endemic for a time; it persisted throughout life, usually without 
causing severe symptoms. 

In the course of febrile diseases, the symptoms of scabies as a 
rule entirely disappear, recurring as soon as convalescence sets in. 

Diagnosis. — The topography and polymorphism of the eruptions, 
the nocturnal pruritus and the contagiousness, make the diagnosis 
probable; the demonstration of burrows or of acari or their ova 
makes it positive. 

The essential point is to keep scabies in mind, whatever the 
environment of the patient; not allowing one's self to be deceived 
by the eruptions of strophulus, prurigo, dysidrosis, pediculosis, 
eczema or pyodermatitis. 

A real difficulty results from the obsession known as acarophobia, 
or fear of the itch; this is observed in persons who have heard of it 



512 PARASITIC DERMATOSES 

and especially in those who have had the disease and been treated 
for it. When pruritus and eczema persist, after treatment by the 
method called "la frotte" to be described presently, baths and 
soothing creams should be recommended instead of hastening to 
resume the treatment, unless new burrows are discovered. 

Treatment. — In order to cure the itch, it suffices to destroy the 
parasite and its ova; no internal treatment of any kind is required. 

The classical "frotte" of the Saint Louis Hospital constitutes the 
most rapid treatment. 

It begins with rubbing the whole body vigorously with soft soap 
for twenty to thirty minutes and continuing the friction in a warm 
bath for another hour, in order to open all the burrows; during this 
time the patient's clothes are disinfected in a steam-sterilizer. 
Xext, the body is thoroughly rubbed with the Helmerich-Hardy 
ointment, which is left on until the next day, when a full bath is 
administered. 

Less irritative sulphur ointments may be utilized, according to 
the formulas of Bourguignon or Fournier (for examples see Thera- 
peutic Notes, §10). 

The "frotte" treatment must not be applied to young children, 
pregnant women, patients with a very delicate skin or those suffer- 
ing from extensive pyodermatitis. In such cases other substances 
may be utilized, such as balsam of Peru, styrax, naphthol, etc., 
which have been tried and approved but which must be employed 
in moderate strength for eight to ten days in succession, at night, 
preferably, after washing with soap; disinfection of the clothing is 
not indispensable. 

("are must be taken always to examine the bedfellow and children 
of the patient, as well as to treat on the same day all who have been 
discovered to be infected. 

Animal Scabies. — Scabies Norwegica or crustosa, described by 
Danielssen and Boeck in lepers, also occurring in Germany and 
various other countries, gives rise to thick and prominent incrus- 
tations which may occupy the entire body, including the back and 
the face. In all probability this condition represents not simply an 
inveterate common itch, but a special parasitical variety, as was 
maintained by Megnin, the sarcoptes of wolves. 

Other animal itches, caused by sarcoptes other than the human 
variety, are very rarely transmitted to man. The absence of 
burrows has almost always been expressly noted. The eruption is 
miliary or polymorphous, diffuse and pruriginous. These abnormal 
itches may be derived from cats, birds, dogs, sheep, goats, camels, 
pigs, etc. They are usually very readily curable or even subside 
spontaneously. 

The most noteworthy and serious form is equine scabies, of which 



DERMATOSES CAUSED BY AC Alii 513 

I observed an example almost identical with the case published by 
Besnier and Megnin in 1892. The appearance was that of a pity- 
riasis rubra, completely generalized; the sarcoptes were demon- 
strable by thousands in the scales and crusts; there were no 
burrows. 

Other Parasitic Acari. — Demodex Folliculorum. — This is a worm- 
like acarus, measuring from 0.3 mm. to 0.4 mm., whose cephalo- 
thorax is provided with a mouth and four pairs of rudimentary feet ; 
the abdomen resembles the finger of a glove and shows fine trans- 
verse striations. 

This parasite inhabits the sebaceous follicles, especially the 
mouths of the large sebaceous glands of the face, with its head 
directed inward; a large number, ten or twelve, may be found in 
the same follicle. 

It has the reputation of being non-pathogenic, causes no inflam- 
mation and certainly plays no part in comedo and acne vulgaris. 
It was held responsible, however, by Dubreuilh, in a case of localized 
pigmentation; personally, I have seen it so abundantly present in 
the horny prominences of a lichen spinulosus that I was tempted to 
attribute an irritative influence to it in this case. 

Certain observations of Borrel would seem to suggest that the 
demodex, or analogous acari, might intervene in the etiology of 
epitheliomas of the face, as irritants or as carriers of a hypothetical 
contagium, as well as in the etiology of leprosy. A disease of dogs, 
known as follicular mange, not transferable to man, is due to a 
variety of demodex. 

Leptus Autumnalis (rouget or aoutat) is the larva of a trombidium 
holosericum which lives on vegetables, notably on beans, wild grapes 
and many varieties of grasses. Certain regions have for a long time 
been infested with it; at present it is spreading in numerous locali- 
ties in the vicinity of Paris. These mites flourish in the summer- 
time and attack those visiting fields or gardens; attaching them- 
selves to the legs, the thighs, the waist and the axillae, especially 
where a band such as a garter or belt, etc., retains them; but they 
are found even on the ears and the face. They cause a frightfully 
itching urticarial papule which the patients scratch off with their 
nails. Careful inspection, preferably with a lens, reveals the para- 
site in the form of a blood-red dot, measuring from \ to ^ mm. in 
the follicular mouth of a hair; often several are seen together. 
Under the microscope, they resemble cheese-mites, but of a red 
color. 

Infection may be guarded against by rubbing with tincture of 
benzoin or oil of cade. The treatment of the very distressing 
eruption caused by the parasite consists in washing with benzene 
or applications of Peru balsam or tincture of iodin. 
33 



514 PARASITIC DERMATOSES 

Ixodes (Ticks).- — The most common (in Europe) is i.nxles ricinus, 
the wood-tick, a large brownish acarus which in the fasting state 
measures from 3 to 4 mm.; its body becomes globular and con- 
siderably swollen when the animal is gorged with blood. It attacks 
dogs, cattle and large game, but rarely human beings. 

Argas. — Argas reflexus marginatus, closely related to the ixodes, 
is of similar size and has the appearance of a small gray shield. It 
is a pigeon-parasite and infests dove-cots. When it accidentally 
bites man, a very painful extensive phlegmonous edema has been 
known to follow, with vesiculation or generalized urticaria, dis- 
tress, tachycardia and digestive disturbances; these symptoms are 
undoubtedly due to inoculation with septic germs. Other species 
of argas and ornithodorus may transmit to man various pathogenic 
agents, notably the spirochete of "tick-fever," etc. 

Pediculoides Ventricosus. — In laborers engaged in unloading 
exotic cereals from various countries and on the boats which carry 
these cargoes, one may observe, sometimes in epidemic form, an 
extremely pruritic erythemato-papular eruption caused by the 
acarus which bears this name. It measures from 120 to 200 fx. 
in length by 70 to 80 /jl. in width. Washing with dilute vinegar 
suffices to cure these patients. [The parasite is conveyed in wheat 
straw and considerable endemics of an urticarial disease have 
occurred in consecmence of the use of the infested straw for making 
cheap mattresses.] 



DERMATOSES CAUSED BY WORMS AND LARWE. 

Among the numerous parasitic worms of man, only one really 
lodges in the skin, namely filaria medinensis. 

Filaria Medinensis or Dracunculus. — This is a nematode worm 
occurring in many tropical countries, notably in Western Africa 
((juiiwa-worm). 

The adult female is filiform and from GO to SO cm. long; it remains 
rolled up in the frequently single abscesses which its presence 
produces, usually on the feet or legs. The filaria is ingested by 
drinking stagnant water in which the embryos have been deposited 
and have penetrated into a small crustacean, a cyclops (Manson) 
[which serves as an intermediate host]. It is not until a year later 
that a fecundated female filaria emerges at the skin. 

In place of the classical treatment, namely extraction of the 
worm by pulling and rolling it up on a small stick, in which 
rupture is a common and dangerous occurrence, it has been 
recommended to inject a solution of bichloride, 1 to 1000, in the 
vicinity of the worm, which dies and is then more easilv extracted. 



EPIDERMOMYCOSES 515 

Filarial elephantiasis (Chapter XVIII) cannot be interpreted 
simply as a parasitic dermatosis. 

Various eruptions have been reported as due to other kinds of 
filaria. Craw-craw is a pruritic papulo-vesicular, later ulcerative 
dermatosis of the feet and legs, observed in Western and Central 
Africa. It is imperfectly known and has been referred to micro- 
filaria (O'Neil), larvse (Nielly), etc. 

Pani-ghao, or ground-itch of Assam and the United States, is a 
papulo-vesicular and pruritic dermatitis due to the larvse of ankyl- 
ostoma duodenale [hook-worm] having penetrated into the skin of the 
feet or legs. 

Cysticercus Cellulosce. — This parasite is sometimes present in the 
subcutaneous tissue of man as well as pigs and is apparently more 
frequent in Germany than in France [and very rare in America]. 
The cysticercus cellulosse is the vesicular form of tenia solium. The 
parasites appear as small and hard, round nodules, the size of a 
large cherry pit, present in more or less considerable number in the 
hypoderm or more deeply, causing neither pain nor inflammatory 
reaction. They contain a clear fluid and a scolex provided with its 
hooks and suckers. The tapeworm whose ova have caused the 
infection not infrequently inhabits the intestine of the patient him- 
self or that of a person in his environment. 

The treatment requires the extirpation, or better, electrolysis of 
each nodule with the positive pole. 

Larva Migrans. — Under this name is designated the parasite of 
a very peculiar affection named creeping disease, pointed out by 
H. G. Lee, in 1874 and 1884. It is characterized by a red line, 
1 to 3 mm. wide, irregularly winding and undulating on the skin, 
sometimes forming knots and loops; its extremity advances from 
1 to 10 cm. daily. This dermatosis is not uncommon in Russia. 
It is difficult to seize the parasite; it is a very motile, black-headed, 
1 mm. long larva of a gastrophilus or horse-fly. The affection may 
be cured by tincture of iodin or bichloride of mercury [by injections 
in front and around the head of the advancing line.] 

Various cutaneous myases due to the larvse of flies (oestridse and 
muscida?) are related affections. 

EPIDERMOMYCOSES. 

The epidermomycoses are caused by mucedinese and are purely 
local affections, without reaction upon the general health. 

Among the thread fungi which are entitled to the name of epi- 
dermophytes, some affect preferably the scalp (tinea XX) or the 
beard (sycosis, XIX) and the nails^ (onychomycoses XXI). 

The same species may also vegetate upon the hairless skin, while 



516 PARASITIC DERMATOSES 

others affect it exclusively; in this way the erythematosquamous ( V) 
and eczemaUform mycoses (IV) originate. 

Favus. — Under this name is designated an epidermomycosis due 
to the achorion Schonleinii. 

Favus, formerly confused like the tineas with porrigo and impetigo, 
was separated by Biett and the brothers Mahon. Its parasite was 
discovered by Schonlein of Zurich, in L839, well described by 
Gruby and christened by Remak. 

Favus is essentially a rural disease, is not limited to children and 
produces crusts and cicatrices; a spontaneous cure is exceptional. 
These features differentiate it from the other epidermomycoses. 

The characteristic eruptive lesion of favus is the scUtulum, a 
saucer-shaped crust 2 to 4 mm. in diameter, thick in proportion, 
of a sulphur yellow color, usually pierced by a thick or downy hair. 




#1- 

Fig. 158. — Favus; spores and separate mycelic fragments. X 900. 

The cup or scutulum originates as a mass of white matter in a 
follicular funnel and at first resembles a small pustule. This mass 
grows and extends in the horny layer, part of which covers it for a 
certain length of time; then it dries, becomes depressed, yellow and 
friable. In three weeks the cup attains a diameter of '.\ mm., and 
may grow still larger. More frequently, neighboring cups of differ- 
ent si/es become agglomerated into an irregular roughened mass 
which has been compared to a honeycomb (favus) and has a mousy 
odor. 

The material of a favus-cup is easily broken up into a grayish 
dust. Examined under the microscope, in a drop of 40 per cent, 
caustic potash or of formic acid, the cup appears composed of spores 
in great numbers and short tubes of mycelium (Fig. 158). The 
mycelial segments, from 4 to 15 fx. long, from ."> to 7 ix. wide, 
are of irregular form, present short lateral branches and often ter- 
minate in a row or tuft of cubical members or spores. These spores 
are rounded, oval or irregular, and of varying diameter; they con- 
sist like the tubules of a granular protoplasm and a not easily 
differentiated membrane, 



SPIDER MOM YC 'OSES 



117 



The achorion is characterized by its abundance as well as by the 
irregularity and clumsiness of its forms. 

In a cross-section of a favus cup (Fig. 159) which is made up 
entirely of parasites, one finds at the base, slender imperfectly 
partitioned threads; in the middle layer, thick sporulated threads, 
at the surface, short members and spores; the whole may be 
covered with lamellae of horny epidermis. 

Malassez observed in a case of favus that the mycelial tubes 
penetrated under the cup as far as the connective tissue of the cutis, 
without exciting a special inflammatory reaction. His specimens, 
which I was enabled to study, are convincing and have been endorsed 
by all histologists who have seen them; but such a penetration is 
exceptional and has never again been demonstrated by myself or 
by others. It certainly does not explain the inflammatory reaction 
caused by favus and the cicatrices which it leaves behind. 




Fig. 159. — Favus; cross-section through a cup imbedded in the epidermis. X 60. 



I have personally described with J. Halle (1910), under the name 
of granuloma favosum, intradermic tuberculoid nodules surrounded 
by a ring of giant cells, found on the scalp in a case of favus. These 
are very rare and are probably due, like the trichophytic granulomas 
of Majocchi, to the destruction of hair follicles. 

In a scale of epidermic favus without cups there are found not 
only a very irregularly partitioned mycelium but also collections of 
spores which are not seen in herpes circinatus trichophyticus. 

The dull and discolored hairs, in favus, are not brittle like tricho- 
phytic hairs, because the parasite is much less abundant in the 
favus hairs. One finds in them a variable number of greatly twisted 
tubules, either thick and sporulated, or slender and more rectilinear, 
composed of segments from 12 to 15/x in length, dichotomized at 
an acute angle and generally surrounded with air-bubbles, which 
at once indicate their presence. 



518 PARASITIC DERMATOSES 

In favus of the nails, the ungual cells are dissociated by irregular, 
slender or very bulky filaments or by spores; this appearance is not 
characteristic. 

Cultures of a particle of a cup or of the root of a favus hair, on 
peptonized agar, yield in three or four days, at a temperature of 90° F., 
a star of white radiating filaments; by the end of three weeks this 
has become an irregular patch, 2 to 4 cm. in diameter, with an 
irregular undulating surface, of a yellowish gray color, smooth or 
covered with a scanty whitish down; its periphery sends out branch- 
ing and nodular radiations. 

The achorion Schonleinii belongs botanically to the genus oospora; 
it is responsible for practically all cases of human favus. Due to 
the remarkable investigations of Sabrazes, Bodin and others, we 
know at the present day several other species of achorion in animals 
— mice, cats, dogs and poultry (achorion Quinckeanum, gallinum, 
gypsceum, oospora canina); but these have been very rarely met 
with in men, in trichophytoid eruptions, sometimes with minute 
cups, but never on the hairy scalp. 

Etiology. Favus is contagious, although to a less degree than 
trichophytosis and is rarely epidemic. It is hardly ever contracted 
otherwise than in the course of childhood, from five to fourteen 
years, at school or at home; it frequently happens that of several 
children who live together only one or two are attacked. As favus 
has practically no tendency to a spontaneous cure, it may persist 
throughout life and become perpetuated in certain families and 
localities. 

Transmission from one human being to another is the rule and 
may be direct or through the medium of clothes, head-coverings or 
toilet articles. Favus of animal origin, as stated above, is extremely 
rare. 

Favoring conditions are dirt, poverty and promiscuity. In Paris, 
cases of favus are almost without exception imported from the 
country or from abroad. The disease tends to diminish in France; 
it is still most frequently met in Lyons, in the northwest and in the 
south. Favus is rare in England and America, but common in 
Poland, Italy, Holland and Algeria. 

Clinical Forms. — Tinea favosa (XX) and onychomycosis favosa 
(XXI) have already been described. I have also pointed out the 
characteristics of the alopecia and cicatrices due to favus (XVII). 

Favus of the glabrous skin is not very rare, but is found especially 
in persons whose scalp has first been infected, so that it is generally 
the result of auto-inoculations. The face, the shoulders, the ab- 
domen, the buttocks and the external aspect of the limbs may be 
attacked. No positive case of favus of the mucous membranes is 
known; the observation of Kaposi and Kundrat, concerning a 



EPIDERMOMYCOSEX 



519 



favus patient who died with gastro-intestinal ulcerations, is open to 
question. 

There are two varieties of favus of the hairless regions (Fig. 160) ; 
the circinate epidermic variety (favus herpeticus) closely resembles 
circinate trichophytic herpes, although it assumes a less regularly 
circular form; the epidermis of the red and scaly spots contains an 
abundance of short mycelial threads, spores and irregular tubules; 
the cupped variety develops as such from the start, or more often 
originates from the preceding form with the appearance of follicular 
yellow disks which grow at a rapid rate. 




Fig. 160. — Favus of the hairless skin; the epigastrium of this young girl presents 
two spots, one of which bears four cups, the other being of the variety known as favus 
herpeticus. 



Treatment. — Favus of the body is much more easily curable than 
favus of the hairy regions. It suffices to soften the cups with moist 
dressings, to remove them by scraping with the curette and to make 
two or three applications of tincture of iodin. As a rule, there remain 
no cicatrices, but only simple macules. Recurrences must be 
guarded against by carefully watching the patient. [The treatment 
of favus of the scalp has been discussed in chapter XX.] 

Trichophytosis. — In a series of remarkable contributions, pub- 
lished from 1841 to 1845, Gruby established the parasitic character 
of the tineas. Credit is due to Bazin for the universal recognition 
of this fact. During fifty years one of these parasites, named the 
trichophyton tonsurans, by Malmsten, was assumed to be the sole 



20 



PARASITIC DERMATOSES 



cause of tinea tonsurans of children, sycosis parasitaria of men, 
herpes circinatus trichophyticus and onychomycosis. 

This view was altogether changed b\ the admirable investi- 
gations of Sabouraud, who confirmed the descriptions of Gruby, 
but applied bacteriological methods to the study of the tinea-. He 
recognized the fad confirmed after him b\ Mibelli, Bodin, ( '. Fox, 
yi ^Jorris, etc. thai the pathogenic trichophytons of men and of 
animals do not belong to one and the same species, but constitute 
a family of numerous genera, varying in their morphology, their 
cultural features, their habitat and the clinical lesions they give 
rise to. 




fticus circi 

iti). 



Moreover, one of the parasites described b\ Gruby in porngo 
decalvans is not botanically a trichophyton; it is called micro- 
sporon and the tinea produced b\ it bears the name of tinea tonsurans 
w ith small spores [microsporia] of Gruby-Sabouraud. It will be dis- 
cussed further on. 

Trichophytons. The true trichophytons belong to the genus 
botrytis, family mucedinea?. 

I,,' their epidermic products, the trichophytons assume the shape 
of mvcelium threads and -pore-. The mycelium is made up of 
elongated, slightlv undulating, regular, colorless and transparent, 



EPIDERMOM YCOSES 52 1 

partitioned and branching tubules (Fig. 161); the partitions are 
usually very close together. In each compartment a rounded, 
oval or cubical spore is formed; these spores often remain in rows 
or strands. 

For the microscopic examination of scales, hairs or nail clippings, 
it suffices to place these on a slide, add a drop of 40 per cent, potash 
solution, cover with a slip and heat gently over a flame to a tem- 
perature near the boiling-point. Formic acid also clears up the 
scales after a little time without heat. Amplification from 200 to 300 
diameters is the most convenient. In order to obtain stained and 
lasting specimens, the epidermic particles must be rendered free 
from fat with alcohol and ether, stained with Sahli's blue and 
mounted in Canada balsam. 

Trichophyton cultures are obtained without difficulty on agar 
media containing 1 gram of peptone and 4 grams of glycerin or sugar 
to 100 grams of water. Barely visible particles of hairs or scales 
should be planted aseptically and the test-tubes left without rubber 
caps at laboratory temperature. Very often the cultures are pure 
from the start, without its being necessary to begin by first washing 
the material in alcohol or silver nitrate, as recommended by some 
authors. After the third day, secondary cultures can be made, 
preferably on the test medium of Sabouraud, which gives the most 
distinctive physiognomy to the various species and is composed as 
follows: Granulated peptone (Chassaing), 10 parts; crude maltose 
(Chanut), 40; agar-agar, 18; water, 1000 parts. A temperature 
from 75° to 95° F. is the most favorable. 

Besides the mycelium, the following organs of fructification of 
the trichophytons are found in these cultures: Spore-bearing 
hyphens usually in terminal clusters, exceptionally endoconidia and 
also, according to the species, more or less numerous multilocular 
spindles. 

The number of known species of pathogenic trichophytons is 
about thirty. 

It has been shown by the investigations of Plato (1902), followed 
by those of Truffi, that a triohophytine can be extracted from the 
cultures of several trichophytons, which when injected into a patient 
having trichophytosis with deep nodes will give rise to a cutaneous 
and a general reaction not occurring in healthy persons. An extract 
of achorion culture, or favine, seems to act even more constantly. 
These injections or applications of salves containing the toxins, 
might serve for the treatment of the deep trichophytoses. Bruno- 
Bloch and Massini have confirmed these observations and have, 
moreover, succeeded in immunizing animals against the tineas in 
general, by a preliminary inoculation w T ith trichophyton gypseum 
or an animal achorion. Investigations in this direction now under 



522 PARASITIC DERMATOSES 

way promise important results from the standpoint of diagnosis, 
prophylaxis and treatment. 

Clinical Forms. — The trichophytons give rise to various cutaneous 
affections, according to their localization on the scalp, the hairless 
skin, the beard or the nails. 

Tinea trichophytica has been described elsewhere | XX). It maybe 
due to several species. According to Sabouraud, it may be stated that 
at the present writing, of 101) cases of this affection in Paris, .10 are 
due to the trichophyton crateriforme, 30 to the trichophyton acumina- 
tum; and the 20 remaining eases are due to various species among 
which the trichophyton violaceum predominates. In other countries, 
these proportions would undoubtedly be different. 

The granuloma trichophyticum of Majocchi (1883-1906) is a rare 
form characterized by intradermic nodules, sometimes agminated 
or in strands, which develop in the cutis of the alopecic and squam- 
ous spots; they consist of a mass of inflammatory cells and a ring 
of giant cells surrounding fragments of trichophytic hairs. Pini 
and Lutati have observed a few similar cases. 

Sycosis trichophytica of the beard, kerion Celsi and folliculitis 
agminata which have already been described in this book (XIX), are 
follicular, inflammatory and even suppurative forms of trichophy- 
toses of animal origin. Their most common germ is the trochophyton 
gypseum of horses; sometimes it is a bird trichophyton with rose- 
colored cultures. These parasites are ectothrix; they possess pyo- 
genic properties. Adults are more susceptible to the contagion 
than children; it results either from direct contact with the tricho- 
phytic animal — horse, dog, cow, birds, etc., whose lesions may not 
always be very evident — or indirectly from the handling of con- 
taminated articles, brushes, coverings, etc. Transmission may then 
take place from man to man, by intermediation of the barber, for 
instance. The sequence of cases is often difficult to establish. 

Jadassohn has pointed out in children suffering from kerion, the 
frequent co-existence of not very persistent folliculitides of the 
trunk, supposed to be of toxemic character and designated as 
disseminated lichenoid trichophytosis. The above statements on the 
etiology of sycosis are likewise applicable to that of onychomycosis 
trichophytica. 

Cutaneous trichophytosis of the hairless- .shin was formerly known 
under the name of herpes drcinatus which also comprised cutaneous 
microsporia and epidermophytosis. 

Cutaneous trichophytosis is observed in: 

1. Children suffering from tinea and persons in their environment; 
these cases are usually due to one of the ordinary endothrix tricho- 
phytons of the tineas. It is not uncommon, as was first pointed out 
by Besnier, that the epidermic manifestation which is very evident 
leads to the discovery of a previously undetected tinea tonsurans. 



EPIDERMOM YCOSES 



523" 



2. Persons of all ages, free from tinea, whose occupation or incli- 
nation puts them in frequent contact with animals. In these cases, 
the parasite is presumably an ectothrix of animal origin and does 
not invade the scalp. 

Any region of the body may be involved; the seat of election of 
cutaneous trichophytosis, however, is the exposed parts, such as the 
face, neck, hands and forearms. Its palmar and plantar localization, 
of special appearance, has been mentioned under the heading of the 
keratodermas (p. 216). 

Trichophytosis of the hairless parts manifests itself in the form of 
erythemato-squamous spots, noteworthy on account of their strictly 
geometrical orbicular circumference and their distinctly outlined 
clean-cut borders (Fig. 162). This feature at once attracts atten- 
tion. It is altogether exceptional for the disk to be incomplete or 




Fig. 162. — Spot of herpes circinatus trichophyticus on a child's neck. 



the circle broken. When the affection is lodged on the fingers, the 
circle is continued from one finger to the other, just as at the eye or 
mouth it passes from one eyelid or one lip to the other. 

The spot is pink or red, often with a dusky center, covered with 
powdery, flaky or crusted scales; it is marginate or plainly cir- 
cinate through healing from the center. 

Another valuable but inconstant characteristic is the vesiculation 
noted at the border of the spot; vesicles may be observed over the 
entire lesion, or there may be several concentric circles of vesicles 
(up to 7 on a cast in the Saint Louis Hospital). Sometimes, the 
vesicular contents are turbid or purulent. The vesiculation is of the 
eczematous type. 

The floor of the spots is sometimes more or less edematous or 
infiltrated. The downy hairs may be dull and brittle or encased in 
scales at their base. Itching is very variable in its severity. 



524 PARASITIC DERMATOSES 

All these variations arc much more dependent upon the kind of 
trichophyton involved than upon individual or accessory factors. 

As a rule, all the spots arc of the same type in a given case 

The coiir.se of herpes circinatus is almost always rapid; in a few 
days, a spot will reach the dimensions of a silver quarter; the exten- 
sion of the borders may he more than 1 nun. daily for some species. 
Slightly older patches may reach the size of the palm or the entire 
hand. Very frequently these spots are multiple and of different 
ages, the most recent spots being the result of re-inoculations. It 
was formerly taught that the confluence of two or more lesions may 
give rise to polycyclic spots or arabesques and that a considerable 
portion of the integument may become invaded; in all probability 
many cases of this kind belong to the group of epidermophytosis. 

The diagnosis of herpes circinatus is often obvious at once 
through the clinical features; in doubtful eases, it will be con- 
firmed by the microscopical examination of the scales from the 
periphery of the lesion. The parasite here appears in the form of 
band-like, slightly wavy, fairly regular, often bifurcated mycelium 
filaments, composed of short members (Fig. 161); even unstained 
specimens show the very close partitions between the square or 
rectangular segments, which is not the case in the mycelium of 
epidermic microsporia. 

( 'onfusion of herpes circinatus must be avoided with the trichoph- 
ytoid patches of common eczema, which are less regularly out- 
lined and accompanied by scattered eczematous lesions; with the 
eczematides, whose configuration is less orbicular and whose course 
is slower; with pityriasis rosea of Gibert, which Kaposi persistently 
classified under "herpes tonsurans maeulosus,'' but which is dis- 
tinguished by is course, its ovaloid patches and the absence of 
vesiculation; it is only the primary patch which may sometimes 
require microscopical examination. 

The distinctive features differentiating the cutaneous trichophy- 
toses from epidermophytosis will be discussed presently. Under 
certain special circumstances, the question of a differential diagnosis 
from various exotic epidermomycoses may arise. 

Treatment by painting with pure tincture of iodin, repeated 
three times at intervals of two days, or with 1 diluted iodin 
tincture in daily applications; or with iodinized vaselin 1 to 
Mid, leads to a cure of herpes circinatus in from ten to fifteen 
days. This medication has replaced the formerly classical employ- 
ment of turpeth-mineral sake I to 1.") and of naphthol ointments. 

Epidermophytosis Inguinalis (Eczema Marginatum of Hebra). — 
The cutaneous affection described by Pr. Hebra, under the name of 
eczema marginatum was recognized as of mycotic origin by Ivobner, 
Pick and Kaposi, but continued to be confused with the cutaneous 



E I' IDE HMO M YCOSES 525 

trichophytoses. The accurate investigations of Sabouraud (1908) 
have demonstrated that it is always due to the same parasite, the 
cpidermophyton inguinale; although very closely related to the 
trichophytons, it differs from these botanically and through the 
fact of its never invading the hairs. 

The eczema marginatum of Hebra has its seat of predilection at 
the inner aspect of the root of the thighs. It begins in this region 
on one or both sides, as one or several nummular spots of a bright red 
color, sharply outlined and pruritic; by their rapid growth, these 
spots become confluent in circinate patches, with red circinate 
borders, often finely vesicular or bordered by white lamellar scales. 
Meanwhile, the center usually fades or remains pigmented, inter- 
spersed with scanty scales and excoriations, or with small crusts 
due to scratching. Around the principal patch, secondary patches 
often originate on the thighs, as far down as the knees, on the pubis 
or the buttocks, taking the same course and sometimes involving 
very extensive surfaces. On the scrotum and penis the lesions are 
less distinct, almost obliterated. The eruption may spread to the 
axillae, the submammary folds, the legs and feet; not infrequently 
it coincides with epidermophytosis of the extremities; unless 
properly treated, it may last for months and years. 

Not uncommonly, especially in men and more particularly in the 
well-to-do classes, eczema marginatum is contagious through sexual 
intercourse and also indirectly through water-closets or underwear; 
as a matter of fact, small epidemics are observed in colleges, work- 
shops, asylums, etc. [The "jock-strap," the hired bathing suit, 
etc., are common sources of infection.] 

Microscopical examination of the scales — which must always be 
taken from the red border — shows an abundance of mycelium 
composed of quadrangular or sometimes ovoid elements, resembling 
that seen in Fig. 161. Cultures grown on test media are radiating, 
powdery, of a lemon yellow color, or downy through pleo- 
morphism. 

Eczema vulgare is distinguished from epidermophytosis by its 
frayed margins and its less restricted localization ; intertrigo, by its 
symmetry and its diffuse margins; erythrasma, by its relatively 
stationary behavior, its dry finely scaly surface, of a uniform dusky 
pink color, without vesiculation of the margins; the mycelium of the 
microsporon minutissimum is infinitely more slender than that of 
the epidermophyton (compare Fig. 161 and Fig. 166). 

Epidermophytosis is differentiated from herpes circinatus tricho- 
phyticus by its predilection for the covered regions, by its tendency 
to become confluent in polycyclic surfaces or in arabesques; the 
patches are not invariably disks or closed circles, but are sometimes 
open on one side. The demonstration of the invasion of the downy 



526 PARASITIC DERMATOSES 

hairs, or cultures of the parasite, may he required in support of the 
diagnosis, but the matter is of no particular importance. 

Treatment by painting daily with iodin tincture diluted with three 
or four parts of 80 per cent, alcohol, is usually sufficient; if neces- 
sary, it may be supplemented by the employment of a zinc salve 
with oil of cade (5%) and salicylic acid (1%). [Whitfield's oint- 
ment, Ac. Salicyl. 1.0, Ac. Benzoic. 2.0, Petrolati, 15.0 is most 
valuable.] Chrysarobin ointments are also very effective, but 
involve the risk of a severe and painful dermatitis. 

Epidermophytosis of the Extremities. — The same epidermophy- 
ton inguinale — as discovered by Sabouraud in 1910 — is the patho- 
genic agent of a very common affection of the interdigital spaces of 
the feet, which was formerly confused with eczema, dysidrosis, 
intertrigo, or maceration due to hyperidrosis of this region. 

The lesions chiefly occupy the floor of the interdigital folds, 
especially between the fourth and fifth toe and the flexion folds of 
the toes. A macerated horny layer is present and becomes detached 
in the form of white shreds, leaving a bright red surface or a cheesy 
material; in the circumference a few vesicles are sometimes seen, 
which may dry or coalesce into an eczematiform surface. This dry, 
vesicular or impetiginous parasitic eczema may extend to the dorsal 
aspect of the foot as well as to the sole, even encroaching upon the 
plantar arch as far as the heel. With remissions and exacerbations 
the disease may be prolonged for many years or indefinitely. 
Through the itching induced by it, the burning sensations and 
superadded pyodermatitis, it becomes a source of distress, interferes 
with the wearing of shoes and may make prolonged walking impos- 
sible. Failure to recognize this dermatosis has often caused the 
patients to be subjected to strict diets, cures in watering-places, etc. 

On the hands and fingers, epidermophytosis is likewise met with, 
although much less frequently, in the form of vesicular lesions or 
squamous, rarely circular exfoliations of the palmar surfaces; it is 
almost invariably confused with a dysidrosis. 

Epidermophytosis of the extremities is accordingly eczematiform 
or dysidrotiform rather than like the palmar and plantar trichophy- 
tosis. Microscopic examination is necessary to establish a positive 
diagnosis; the mycelium is abundantly present in the scales. Cul- 
tures arc difficult on account of bacterial contaminations. 

Treatment. — The treatment is the same as that of inguinal mar- 
ginate eczema, but in view of the thickness of the horny layer, the 
action of the dilute iodin tincture must be reinforced by moist 
dressings during the night, followed by careful scraping and cleans- 
ing. Sabouraud recommends an ointment of lard and chrysarobin 
(1 to 3 to 100) with salicylic acid (5 to 100), avoiding all washing 
with soap and water. [In my experience, a five-day course of 
i)reuw's ointment is incomparably the most effective treatment.] 



EPIDERMOMYCOSES 527 

Microsporia. — The parasite of tinea tonsurans with small spores, 
the microsporon (p. 421), was discovered by Gruby, then misinter- 
preted, lost, and re-discovered by Sabouraud in 1892. It differs 
from the trichophytons in its microscopical and botanical features 
and in the appearance of the lesions produced by it. The contri- 
butions of Adamson, C. Fox and Blaxall, Bodin, etc., and especially 
the work of Sabouraud, collected in his book on The Tineas, 1910, 
have definitely settled the scientific data concerning it. 

The microsporon Aiidouini — the first discovered, which infests 
especially Northeastern Europe, is at the present time endemic in 
England, causes two-thirds of the cases of microsporic tinea ton- 
surans in Paris and is responsible for the epidemics in children's 
asylums and schools — is now known to be not the only species met 
with in man. 

There are about ten other microsporons which are for the most 
part of direct or indirect animal origin (m. lanosum or caninum, m. 
felinum, m. equinum) and give rise in nearly all countries of the 
earth to sporadic cases or small family epidemics. 

The microscopical demonstration and the culture of micro- 
sporons are the same as those of the trichophytons. Cultures of 
the microsporon Audouini, on the maltose medium of Sabouraud 
and at room temperature, become visible on the fifth day, measure 
5 cm. at the end of a month and resemble a layer of white or grayish 
short-nap wool. Cultures of microsporons of animal origin are of 
quicker growth and more downy, their fluff showing abundant 
multilocular spindles under the microscope; furthermore, the last- 
named cultures undergo from the fifth week on a downy pleomorphic 
degeneration, not shown by cultures of the microsporon Audouini. 

Microscopical examination of microsporon cultures shows modes 
of reproduction akin to but different from those of achorions and 
trichophytons, in the form of pyriform swellings on the filaments, 
large spindle-shaped and partitioned conidia, pectinate hyphens, 
clusters of cylindrical and sessile conidia, etc. 

The microsporon Audouini affects exclusively the scalp of chil- 
dren, where it causes the microsporic tinea which has been described 
elsewhere in the work (XX). 

It very rarely vegetates on the hairless skin, where it produces 
scaly pinkish spots of ephemeral character and self-limited duration. 

Animal microsporons outside of the hairy scalp and even in adults 
sometimes cause erythemato-squamous, nummular or circinate, 
pink or dun-colored spots, in large numbers, exceptionally even 
generalized over the entire body. These spots of cutaneous micro- 
sporosis may last a month and a half. A few cases of microsporic 
sycosis of the beard have been observed in men. 

In the scales of tinea tonsurans with small spores, or in those of 



528 PA RA 81 TIC DERMA TOSES 

epidermic microsporosis, examination in potash solution shows 
abundant twisted and serpentine filaments, with apparently few 
partitions, frequently bearing small lateral protuberances. After 
staining, this mycelium appears divided into septa at short intervals. 

Tropical Epidermomycoses. Tokelau or Tinea Imbricata. — This 
dermatosis is endemic in the islands of the Pacific and in Indo-( 'hina. 
It is observed in natives of all ages. 

The disease, which persists throughout life, manifests itself as 
regular erythemato-squamons concentric circles. The shell-like 
scales are adherent at their peripheral portion, loose at their central 
portion and overlap like the tiles of a roof. The circles and their 
underlying patches increase in number and size, become interrupted 
through a variety of factors, until the entire integument becomes 
covered with squamous arabesques, including the face, the extremi- 
ties and the nails, but not including the scalp. The patient roughly 
resembles a case of ichthyosis; he suffers from severe and continuous 
pruritus. 

The microscope shows a dense network of branching and spore- 
bearing mycelium in the scales; the condition is referred by Manson 
to a trichophyton capable of inoculation from man to man but 
not growing in cultures, namely the trichophyton concentricum of 
Blanchard; Tribondeau describes the organism as aspergillus 
lapidophyton. Castellani reports successful cultures and inoculations 
of endodermophytons. 

Carates and Central A merican Epidermomycoses. — Under the name 
of carates, mat del Pinto, or Pinta, are designated numerous epidermo- 
mycoses due to chromogenic parasites, widely distributed in tropical 
America and although known for a long time, as yet inadequately 
studied. They are characterized by spots which become confluent 
in large desquamating lobulated patches and may become general- 
ized. There exists a black, blue, violet, red, yellow and a white 
variety; all, except the red one, may ultimately turn white. The 
odor is offensive, the hairs fall out, the nails remain intact. Asso- 
ciation with scabies is common. The scales enclose a profuse tangle 
of mycelium. The chromogenic parasites, studied by Montoya, 
belong to the groups of aspergillus, penicilium, monilia, montoyella, 
microsporon and trichophyton. 

Aside from these carates, various imperfectly known epidermo- 
mycoses are met with in Central America, which give rise to red 
patches covered with white scales, sometimes hyperkeratotic, with 
polycylic contours; they may attack the nails and are of indefinite 
duration. In a case (Fig. 163) observed by me in a patient from 
Ecuador, published in 1903, the scales enclosed a network of a 
mycelium which Bodin (of Rennes) successfully grew in cultures; 
he found it to be related to trichophytons and still more closely to 



EPIDERMOM YCOSES 



529 



the lophophyton gallinse, the parasite of chicken-favus, which 
causes the "white comb" in fowls. There are probably more or less 
analogous epidermophytoses due to various fungi in many tropical 
countries. 

The treatment of these exotic mycoses is extremely tedious. I 
have obtained the best results with chrysarobin in ointments (of 1 
to 3 per cent.), or in varnishes like traumaticine. 




Fig. 163. — -Central American epidermomycosis of seven years' standing, diagnosed 
as carate; note the lesions of the nails and genital organs. The patient suffered at the 
same time from scabies. 



Pityriasis Versicolor. — Pityriasis versicolor is a parasitic affection 
of the epidermis, characterized by yellowish and scaly spots, caused 
by the microsporon furfur or malassezia furfur. 

Confused by the ancients with pigmentary spots, pityriasis 
versicolor was distinguished from these by Willan, who classified 
it among the squamous diseases and gave it the name it bears. 
Eichstedt, in 1846, discovered the parasite, which was christened by 
Ch. Robin. 

Pityriasis versicolor manifests itself as sharply defined patches, 
varying in color from a dirty yellow, tan or chamois to a dark brown, 
sometimes with an admixture of a pinkish shade. The color varies 
in different persons, different regions, and even on the same spot at 
different times; hence the name of versicolor. In the colored races, 
the spots are lighter than the normal skin and achromic by contrast. 

The spots are slightly scaly, powdery or entirely smooth. Their 
34 



530 PARASITIC DERMATOSES 

essential feature, however, is that the horny epidermis is here less 
adherent than under normal conditions, so that on vigorous scratch- 
ing with the nail a desquamated shred becomes detached without 
bleeding. This "nail-scratch or flake sign" is almost pathognomonic 
and is due to the fact that the presence of the parasite permits the 
superficial horny layers to slide over the deeper layers. 

The spots are not prominent. Their shape and dimensions are 
extremely variable. They may be punctate, guttate, in disks, 
rings or patches, or cover large surfaces with geographical contours, 
sometimes involving a large portion of the thorax; these various 
configurations are often seen on the same individual. 

Any region of the integument may be the seat of pityriasis versi- 
color, with the exception of the hands and feet. Its seat of election 
is the upper part of the chest, in front and behind, whence it reaches 
the shoulders, the flanks, the abdomen, the groins, the arms and 
rarely the legs. It is exceptionally observed on the neck, the chin 
and even on a large portion of the face. 

The growth of the vegetating parasite as a rule causes no itching 
at all, so that the patients are not aware that they are affected with 
a parasitic dermatosis. The duration of the disease is always very 
protracted and indefinite; it may, however, heal spontaneously, 
for it is never met with in the aged. It progresses and becomes 
aggravated under the influence of sweating and in the absence of 
ablutions and remains stationary under contrary conditions. 

Microsporon furfur grows exclusively in the horny layer and pro- 
duces no inflammatory reaction. It never invades the hairs. In 
the shreds detached with the finger-nail may be seen (after clearing 
with potash and under a magnification of 300 diameters) numerous 
clusters of fifteen to thirty round spores, with double contours, 
measuring from 3 to 5 /*. From these masses, radiating and inter- 
laced mycelium filaments which traverse the intermediate spaces 
are given off. They are winding, short, somewhat irregular, slightly 
branching, divided by septa and in places spore-bearing (Fig. 164). 

The culture of microsporon furfur, remarkably enough, meets 
with great difficulties; successful cultures were grown by Mat- 
zenauer and Nicolle, the latter using glycerin-agar. 

The etiology naturally depends upon the transmission of the 
parasite. But pityriasis versicolor is very slightly contagious; it 
is rare for husband and wife to infect each other or to convey the 
contagion to their children. Kobner after many attempts succeeded 
in inoculating himself and in infecting rabbits. The incubation 
lasts over a month. 

This epidermomycosis is common among adolescents and adults 
of both sexes; it is very rarely seen at an early age. In all prob- 
ability it requires special regional conditions. The influence of a 



EPIDERMOM YCOSES 



531 



tuberculous soil has been exaggerated; for some time, a relation 
between the microsporon and the agent of tuberculosis was erro- 
neously surmised. The frequent coincidence is probably accounted 
for by the sweating of consumptives, the habitual wearing of 
flannels and the fear of bathing. 

The diagnosis is based essentially upon the "flake sign;" a 
microscopical examination is almost superfluous. If only the phy- 
sician will think of looking for this sign, a confusion with congenital 
pigmentary spots, chloasma, pigmentary syphilides, eczematides, 
etc., is impossible. The distribution of certain pigmentary spots of 
leprosy may be analogous to that of pityriasis versicolor. 




Fig. 164. — Microsporon furfur in a scale from pityriasis versicolor; stained with 
Sahli's blue. X 325. 



Although common pityriasis versicolor may occur, as I have 
myself seen, among the inhabitants of Annam and Cambodia, 
there is in addition a tropical pityriasis versicolor, or tinea flava, or 
parasitic achromia with estival exacerbations (Jeanselme). This 
epidermomycosis is very common in the far Orient and is character- 
ized by yellowish, slightly scaling spots which preferably occupy 
the face, neck and upper trunk, is of very slow development and 
difficult to cure. It is caused by malassezia tropica (Castellani, 1905) 
which has a short, swollen or club-shaped mycelium with spores 
not always arranged in clusters. 

The treatment of pityriasis versicolor must aim at removing 
the horny layer which alone harbors the parasite. Not a spore 
must be left behind, so as to guard against recurrence; on the 
other hand, unnecessary irritation must be avoided. Tincture of 
iodin, employed as in herpes circinatus, lard with chrysarobin 
(1 to 1000), or simply soft-soap rubbed on for ten minutes followed 



532 



PARASITIC DERMATOSES 



by a bath, arc usually sufficient. For regions where the skin is 
sensitive, in the groins or in the axillae, recourse may be had to 
naphthol (1 to 30) or sulphur (1 to 20) salves and to salicylic acid 
ointments (1 to 30), not forgetting washes with soap and baths, as 
well as disinfection of the body linen. [A simple and effective treat- 
ment consists in a daily bath with soap followed by a sponging with 
a 1 to 8 solution of photographers' Hypo for a week; the course of 
treatment, whatever it may he, should he repeated after two weeks' 
interval.] 

Erythrasma. The practitioner is usually not so well acquainted 
with this disease, although it is as common as pityriasis versicolor; 
it is an epidermomycosis due to the microsporon minutissimum and 
appears in the form of brownish or yellowish-pink patches especially 
in the inguinal folds. 



Fig. 165.— Erythrasma 
.somewhat more extensive 
i um of Hebra. The micrc 
iMUT (,!' microsporon miimt 




The territory occupied by the epidermomycosis was 
um usual in this case, which resembles eczema margina- 
lope showed the abscess of epidermophyton and the pres- 



Erythrasma is found in adult or old men, of all social classes, much 
more rarely in women and never in children. 

Its origin always escapes attention; the patients are usually 
unaware of having it and are ignorant of its onset. Subjective 
symptoms are absent; sometimes moderate itching is noted after 
sweating. The course is very slow; the duration is indefinite. 

The seat of election of this dermatosis is in the genitocrural fold 
high up on the internal aspect of the thigh (Fig. 165); it rarely 
encroaches upon the pubis and the scrotum. The lesions are uni- 
lateral or bilateral. Much more rarely the axillae are also involved. 

The erythrasma patch, ordinarily from 5 to 12 cm. wide in all 
diameters has an always distinct, polyeyclic and serrated circum- 



EPIDERMOMYCOSES 533 

ference; outside of the principal patch, small islands of the same 
character may be found on the thighs, the abdomen and elsewhere, 
but this is altogether exceptional. The color is uniform as a rule 
but very variable according to the moment when seen, dark red, 
deep yellow, brownish with a tinge of pink. The surface is level, 
powdery, finely squamous, and often criss-crossed in very fine folds. 
It is oily and moist during perspiration. 

Examination of the scales under the microscope, with a magnifi- 
cation of 400 diameters, after treatment with potash solution, 
serves to demonstrate the parasite in some cases, but not easily. 
It is better, after removing the fat with ether, to stain the scales 
with Sahli's blue or with phenol-thionine (Fig. 166). 












Fig. 166. — Microspores minutissimum in a scale of erythrasma. Stained with 
Sahli's blue. X 1000. 



This parasite is the microsporon minutissimum, or discomyces 
minutissimus , discovered by Burchardt in 1859. It appears in the 
form of very fine filaments, less than 1 n wide, twisted and branching, 
apparently fragmented and provided with spores at their extremi- 
ties. These filaments are extremely abundant and constitute a real 
network between the horny cells. Culture of the discomyces is 
difficult; but Michele, Ducrey and Reale seem to have obtained it 
and were able to inoculate it on man. 

Erythrasma is very slightly contagious; it is rare for husband and 
wife to be simultaneously affected. 

Transmission possibly takes places through underwear, water- 
closets, etc. 



534 PARASITIC DERMATOSES 

The diagnosis is obvious in the majority of the cases, although 
sometimes difficult. 

Intertrigo is more inflammatory and has no sharply defined 
contours. Eczematides are rarely so narrowly localized. Partial 
prurigo is highly pruritic and lichenized. Inguinal epidermo- 
phytosis is of a bright red color, is polycyclical and marginated, takes 
a rapid course and has a much larger parasite. 

The treatment is analogous with that of pityriasis versicolor 
and inguinal epidermophytosis, but erythrasma is more rebellious. 
In a few weeks an apparent cure is obtained, but great persever- 
ance is needed in order to avoid a recurrence. [The interrupted 
or discontinuous method of sterilization yields the best results 
in this as in many other infectious diseases. In erythrasma as in 
pityriasis versicolor one week of treatment should be followed by 
two weeks of rest, and several courses of treatment are usually 
necessarv.l 



CHAPTER XXjVI. 
INFECTIOUS DERMATOSES— PYODERMATITIDES. 

In the following chapters (XXVI to XXIX) I shall discuss the 
infectious dermatoses whose parasitical agent is established, known 
and specific, or practically specific. 

Some are referable to internal infections, such as syphilides, the 
rose-spots of typhoid fever, of some tubercular eruptions, etc. 

Others are due to external infections, like the pyodermatitides, 
soft chancre, some cutaneous tuberculoses, Biskra boil, etc. 

The following review, however, by no means exhausts the question 
of the part played by infections in skin diseases. 

For many eruptions the causative infectious agent is still unknown 
(example: eruptive fevers); or it is not specific, in the sense that 
different microbic species may lead to the same syndrome (examples : 
purpura, ulcers, multiple gangrenes, elephantiasis) ; or it is secondary, 
superadded, perhaps accessory (examples: eczema, artificial der- 
matitides, etc.). 

Finally, in many cases, the role of an infectious agent is theo- 
retical, suspected or vaguely surmised (examples: polymorphous 
erythema, secondary and primary infectious purpuras, primary 
erythrodermas, warts, vegetations, pemphigus, acute nodosities, 
molluscum contagiosum). 

According to the plan here adopted, these various syndromes 
figure only in the first part of this work, which is devoted to the 
morphology of skin diseases. In this part only pathological entities 
with an established infectious etiology are considered. 

These infectious dermatoses, according to the nature of their 
pathogenic agent, may be classified as follows : 

1. Infectious dermatoses caused by cocci: these are the pyo- 
dermatitides, to be discussed first of all. 

2. Dermatoses caused by bacilli, or infectious bacillary dermatoses 
(XXVII). 

3. Infectious dermatoses caused by vegetable parasites of an 
order higher than the cocci and bacilli: dermatomy coses (XXVIII). 

4. Infectious dermatoses due to protozoa: spirochetes, leishmanias, 
etc. (XXIX). This group comprises syphilis and a few more or less 
analogous exotic dermatoses. 



536 INFECTIOUS DERMATOSES— PYODERMA T I TIDES 



PYODERMATITIDES. 

The acute inflammations of the skin due to the ordinary microbes 
of suppuration or pyococci are called pyodermatitides. 

Pyococci. — The vast majority of suppurations of the skin are 
caused by two groups of microbes: staphylococci and streptococci. 
In each of these groups numerous varieties or species are distin- 
guished which are interpreted by some bacteriologists as simple 
strains. These varieties differ from each other in their morphology, 
their cultural characteristics, their habitat and — what is especially 
of clinical interest — in their virulence. 

Staphylococci are cocci of somewhat variable size, which appear 
in pus in the form of diplococci, or in a series of three or four granules; 
in cultures they are arranged in masses or clusters. 

They grow readily on most of the ordinary artificial culture media, 
preferably at 37°; they have a variable chromogenic capacity which 
is the basis of a differentiation between the cocci obtained from the 
pus, as follows: Staphylococcus aureus, Staphylococcus albus, Staphy- 
lococcus citreus, etc.; they liquefy gelatin more or less rapidly; 
they possess a high degree of vitality. 

Nearly all staphylococci are pyogenic; on inoculation they pro- 
duce subcutaneous abscesses, peritonitis, etc., in the majority of 
animals. When injected into the ear-vein of rabbits, they give rise, 
according to dosage and virulence, to a rapidly fatal septicemia, 
miliary abscesses of the kidneys, arthritis, osteomyelitis, endo- 
carditis, etc. Garre, Bockhart and Rodet produced folliculitis, 
impetigo, furuncles, etc., by rubbing cultures upon the human skin. 

Up to ten varieties or species of staphylococci have been described. 
One of great importance on account of its abundance on the skin is 
designated under the names of Staphylococcus cutis communis, or 
Coccus iwlymorphis of Cedercreutz. This microbe, which undoubt- 
edly corresponds to the morococcus of Unna, presents itself in the 
scaly crusts of eczematides under the aspect of mulberry-shaped 
clusters; it groAvs on glycerin-agar in porcelain-gray streaks or 
drops and gives off a butyric odor. It does not liquefy gelatin. It 
is usually considered as non-pathogenic, but its inoculation on the 
human skin has been known to cause folliculitis or small vesicles of 
eczema. 

Staphylococci are widely distributed in the air, in dust and in 
water; they are regularly present in the mouth, at the natural 
orifices, and are disseminated on the skin. 

Streptococci are cocci arranged in small chains of variable 
length, often composed of diplococci; the size of the granules 
varies. Streptococci will grow on all ordinary culture media, pref- 
erably under anaerobic conditions; the optimum temperature is 



PYODERMATITIDES 537 

37°. They do not liquefy gelatin and form flakes in broth-cultures; 
their vitality is readily destroyed by the air. In order to isolate a 
streptococcus contaminated with other cocci, Sabouraud recom- 
mends growing the first culture in a pipette in bouillon or ascites- 
fluid; or, according to a familiar procedure, the suspected material 
may be planted on several slanting tubes of peptone-agar and 
numerous streak-cultures planted without recharging the platinum 
needle. 

The virulence of different streptococci varies to an enormous 
extent. The streptococcus of erysipelas, discovered by Fehleisen, the 
Streptococcus pyogenes of Ogston and Rosenbach and the strepto- 
coccus of puerperal infection, undoubtedly belong to a single species. 
As regards other varieties, differing in their morphological and bio- 
logical features as well as their habitat, the question has not yet 
been settled. 

On inoculation into a rabbit's ear, a very virulent streptococcus 
gives rise to fatal septicemia; a less virulent germ causes erysipelas; 
a still weaker one will produce an abscess. By means of intravenous 
injections into animals, practically all the affections caused by 
streptococci in human beings have been successfully reproduced. 

Streptococci have their ordinary habitat in the air, in the ground, 
on the skin and especially in the mucous cavities. They are less 
frequent on the epidermis than staphylococci, but are constantly 
present in the mouth of healthy individuals. 

The relations existing between the Streptococcus pyogenes and the 
Streptococcus of the saliva (Veillon), the Streptococcus of scarlet 
fever, the small granular streptococcus, those which liquefy gelatin 
or are encapsulated, etc., have not been definitely established. Up 
to 46 species have been described (Gros). 

Other microorganisms in large number, but not properly speaking 
pyococci, are likewise more or less commonly encountered on the 
skin and in the surroundings of the natural orifices, such as : various 
micrococci; the bacillus of seborrhea, epidermidis, cutis commune, 
subtilis fluorescens, coli, pseudodiphtheriticus , the bottle-bacillus or 
Malassez spores, etc.; furthermore, a sarcina, a leptothrix, various 
saccharomyces, etc. 

The germs of the skin vary enormously in number according to 
circumstances. The average is assumed to be 40,215 per square 
centimeter; from 85 millions to 1212 millions of germs are left in a 
bath, according to Remlinger; they flourish with especial luxuriance 
in the moist and hairy regions of the body. Sabouraud has shown 
that they are more abundant around pathological lesions of any 
kind. Their principal receptacles aside from the mucous orifices 
are the follicular funnels which constitute both a shelter for the 
germs and the weak point in the epidermic armor (Chapter XIX). 



538 INFECT 10 US DERMA TOSES—P Y ODER MA TI TIDES 

It must be understood that no scrubbing or ever so careful and 
prolonged disinfection can be relied upon to remove or destroy all 
the microbic inhabitants of the epidermis. With special reference 
to pyodermatitis, it may be said that the seeds are practically 
ubiquitous. However, the absence of cleanliness, contact with con- 
taminated individuals, with soiled clothing or other articles, will 
naturally greatly increase the chances of infection. 

Pathogenesis. — In this respect, four points require attention: the 
portal of entry, the virulence, the resistance of the soil and the patho- 
genic mechanism. 

A. The portal of entry of pyogenic microbes is external in the 
vast majority of the cases. It is only in the pyemias, etc., that they 
reach the skin by the vascular route, giving rise to intra- or sub- 
dermic abscesses. 

The protective barrier formed by the horny layer is removed 
through traumatisms of all kinds, by parasitis such as sarcoptes or 
lice and by scratching in case of pruritus. It is likewise impaired 
by maceration or chemical lesions of the epidermis, such as those 
caused by poultices, plasters and strong antiseptics like bichloride 
of mercury, carbolic acid, etc. It is noteworthy that the latter are 
usually more injurious for the epidermis than for the germs con- 
tained in it, thereby favoring the propagation of the pyodermatitis. 
The present tendency therefore is to replace the antiseptic dressings, 
which were so popular in the past, by aseptic dressings. 

The reason why the follicular orifices so often become the portal 
of entry of infection is that they are usually already inhabited by 
germs and on the other hand are easily damaged by friction, move- 
ments, etc. Preexisting lesions of the epidermis, eczematization, 
vesicles and bulla 3 , offer a ready-made culture-medium for the 
pyococci; secondary infection, superadded suppuration or impetigi- 
nization is therefore extremely common. 

It is often difficult to estimate the relative significance of the 
primary cause and of the secondary infection, as a matter of fact, 
various chemical substances and certain specific microbes may be 
pyogenic in themselves. 

B. The degree of virulence of the parasites, pyococci and others, 
is extremely variable, not only according to the species or strain, but 
in the same strain. Some behave like simple saprophytes; others 
again are highly pathogenic. The virulence of a microbe may be 
attenuated or exalted by different laboratory procedures. Clinically, 
it is governed by conditions not all of which have been established; 
the best known although not the only cause of increased virulence is 
primary growth in a pathogenic focus, the effect being comparable 
to the well-known increased virulence by passage through an 
animal; it accounts for the auto-inoculations, the contagiousness 



PLATE II 



BOCKHARDT'S IMPETIGO (X 10) 



MPETIGO OF TILBURY FOX (X 12) 




Schematic Comparison of the Pyodermatitid.es. 

Pus and necrotic tissues are shown in yellow ; the dots indicate 
approximately the relative abundance of polynuclears in the epidermis 
and in the cutis. The amplification is stated with the name of each 
variety. 



PYODERMATITIDES 539 

and persistence of some pyodermic lesions. A very considerable 
number of common microorganisms are actually under suspicion, 
being capable of assuming pathogenic properties under a variety of 
circumstances. 

C. The resistance of the soil against pyococci is also extremely 
variable. Although immunity against them, either temporary or 
permanent, does not exist, the susceptibility is evidently increased 
under certain conditions. In children and youthful individuals, 
such conditions are represented by the so-called lymphatic consti- 
tution or scrofulous diathesis, by undernutrition, general weakness 
and convalescence from disease. In adults, overexertion, general 
nutritional disturbances, such as diabetes and cachexia, likewise 
create a predisposition for pyodermatitides. The part played by 
local circulatory disturbances or nutritional disturbances of the skin 
manifests itself for example in varicose limbs. These factors explain 
not only the easy onset of superficial pyodermatitides but also 
their multiplication, their liability to recurrence, their obstinate 
character and the tendency to complications with lymphangitis, 
abscesses, adenitis and to termination in the grave forms of staphy- 
lococcia and streptococcia which may lead to death in weakly 
children and cachectic individuals. 

D. Staphylococci and streptococci both possess, undoubtedly 
due to their secretions, a vasodilator action and an attraction for 
leukocytes known as positive chemotaxis. Under their influence the 
skin becomes congested and the white corpuscles swarm into the 
cutis, or, according to the case, into the epidermis, together with a 
certain amount of plasma. Certain differences are noted, however, 
between the properties of the two groups of pyococci. 

The staphylococci attract especially the polynuclears and pro- 
duce the smooth, creamy, thick pus which was formerly described 
as "laudable pus." The streptococci are in a general way less 
pyogenic; they give rise rather to an outflow of plasma and the 
secretion of a turbid serous fluid or of thin serous pus. However, 
according to Jadassohn, staphylococci may also give rise to serous 
bullae. The Staphylococcus aureus, moreover, possesses necrotizing 
properties, as shown by the core of furunculus and the slough of 
carbuncle. Mixed infection produces intermediate effects. 

Clinical Forms. — A series of pathological types is referable to the 
penetration of pyococci into the epidermis, into the pilosebaceous 
follicles, or into the cutis. I have endeavored to convey an idea of 
the principal types in the subjoined schematic figures (see Plate II). 

Among the staphylococcic pyodermatitides of external origin, I 
have already described Bockhardt's impetigo, impetiginous eczema, 
ostiofollicular pustules and deep folliculitis, sycosis, etc. Furun- 
culus, carbuncle and hidrosadenitis will be discussed further on. 



540 INFECTIO I >' DERMA TOSES -PYODERMA Tl TIDES 

Abscesses, diffuse phlegmons [cellulitis] and suppurating wounds 
belong to the domain of surgery. 

Staphylococci brought to the skin by way of the blood give rise 
to multiple and successive emoblic abscesses, as one of the mani- 
festations of pyemia, which is accompanied by grave general 
disturbances. 

I have previously had occasion to state that the miliary abscesses 
of little children are not referable to the last named pathogenesis, 
as formerly believed to be the case, but that they are the result 
of an ascending infection of the sudoriparous canals. 

I repeat that an association of various pyococci may be held 
responsible for impetigo vulgaris and ecthyma (pp. 165, 169), for 
various ulcers (XV), probably for pustular acne (p. 386), the microbic 
eczemas (p. 66) and the eczematides (p. 97), as well as for 
impetiginous onyxis (p. 434). 

Referable to cutaneous streptococci a are: the impetigo of Tilbury 
Fox, ecthyma, leg ulcer, erysipelas (which is not usually considered 
in the scope of dermatology), the lymphangitides, lymphangitic 
abscesses, phlegmons and adeno-phlegmons, which belong to the 
domain of surgery. 

Perleche. — Perleche — a very trifling affection, interesting on 
account of its contagiousness and the diagnostic errors which it 
occasions — consists of a circumscribed redness of the two labial 
commissures, with maceration of the epidermis and often fissure- 
formation. It is frequent in children who contract it in school and 
transmit it to the family; it may last for weeks and months. Some- 
times it coexists with impetigo vulgaris or impetiginous stomatitis. 

Perleche seems to be a simple regional streptococcia. By J. 
Lemaitre, who described it in 1886, it was attributed to a so-called 
Streptococcus plicatilis, which is probably in no way specific. 

A differential diagnosis must be made from herpes, which is 
rarely bilateral and always vesicular at the onset; and especially 
from mucous patches, but these are accompanied by other manifes- 
tations of secondary syphilis. 

Perleche is treated like impetigo. Silver nitrate, Alibour water, 
yellow precipitate ointment, or steresol, etc., will promptly check 
it. The children must not be allowed to kiss and their glasses and 
tableware should be washed in boiling water. 

Finally, there occurs nonsuppurative manifestations of the various 
pyococcias, such as certain purpuras (Chapter III), probably botryo- 
mycoma (p. 704) and perhaps the necrotic and keloid forms of acne, etc. 

Furunculus. — A furuncle or boil is a massive folliculitis with a 
usually very acute inflammatory course and necrotic character. 
Boils are due to the Staphylococcus aureus, as discovered in 1880 



PYODERMATITIDES 541 

by Pasteur, who soon afterward was able to demonstrate the 
"microbe of furuncle" in osteomyelitis. 

Whether it be derived from a contagion, or what is more common, 
from auto-inoculation of another staphylococcic lesion, the microbe 
must necessarily have been introduced rather deeply into the follic- 
ular canal in order to produce a furuncle. Hence, boils preferably 
develop in regions exposed to rubbing from clothes or implements of 
work; they are common in rag-pickers, refiners, mechanics, riders, 
etc. Fatigue, nervous disturbances, errors in diet and convalescence 
from acute diseases are predisposing factors. Diabetes mellitus 
especially constitutes such a favorable soil that the urine should be 
examind as a routine procedure in all cases of furunculosis. 

In certain individuals, through the effect of a very marked pre- 
disposition or rather because immunization does not occur as under 
normal conditions, boils follow one another for a period of months 
and years. This furunculosis may be connected with a run-down 
condition, auto-intoxications, etc.; but its cause often remains 
undemonstrable. 

A furuncle begins with a red acuminate elevation with a hair in 
its center; its two essential features are induration and pain. There 
is often considerable edema of the vicinity. In three to five days, 
the growing protuberance has assumed a purplish, later pustular 
apex. Having reached maturity, the furuncle softens and opens; 
after a flow of pus, a core or slough is eliminated, consisting of 
necrotic cellular tissue infiltrated with pus. The pain subsides as 
soon as the discharge of pus is freely established. 

A furuncle always leaves a more or less visible cicatrix, unless it 
has been aborted, spontaneously or as the effect of treatment; in 
this case, the induration lasts from three to twelve days and finally 
becomes absorbed. In weakened or diseased persons, boils are 
accompanied by extensive edema, fever, malaise, etc. 

Boils may be situated wherever there are hair follicles, but the 
site of election is at the nape of the neck; next in order follow the 
back, the buttocks, the lower limbs, the forearms, etc. 

Furuncle of the upper lip gives rise to a severe and very alarming 
inflammatory tumefaction, and the possibility of lymphangitis, 
phlebitis and meningeal complications must be borne in mind. 

Furuncles of the auditory meatus are noteworthy on account of the 
resulting pain, which is very severe, radiates widely, interferes with 
mastication and prevents sleep. These furuncles are often asso- 
ciated with auricular eczema; they have a tendency to recur and 
may affect one ear after the other. 

A furuncle differs from ordinary suppurative folliculitis by the 
severity of the inflammatory reaction, the induration of the tissues, 
the pain and the core or slough. It is distinguished from hidros- 



542 INFECTIOUS DERMATOSES— PYODERMATITIDES 

adenitis, which moreover is practically limited to the axilla, by its 
acuminate form and by its core. The differential diagnosis from 
malignant pustule [anthrax] may, in exceptional cases, prove some- 
wliat difficult. 

Treatment. — At the onset, abortive treatment may be tried; for 
this purpose, a finely pointed galvanocautery or thermocautery 
needle may be inserted in the center of the furuncle, or it may be 
painted twice, at an interval of twelve hours, with iodin tincture 
or iodo-acetone. The adjacent skin should be cleaned with an 
antiseptic soap and washed with camphorated or resorcinated alcohol. 

In its developed stage, the furuncle must not be irritated by 
strong antiseptics, which would cause a complicating artificial der- 
matitis, without any benefit whatever. It suffices to make two daily 
applications of a hot spray with weak carbolic, resorcin, or pheno- 
salyl water, or simply washing with Alibour water; the parts are 
then covered with cotton wadding, moist dressings with boiled water, 
or still better with a layer of cotton covered with borated starch 
glycerolate (1 to 10), which affords a better protection against 
neighborhood inoculations. 

I have never found it necessary to incise a furuncle. It would be 
more justifiable to perform complete excision at the onset, provided 
the patient and the locality permit. The pain caused by interstitial 
injections, even with gaseous oxygen is not offset by their advan- 
tages. In the period of repair, it is advisable to cover the orifice 
with mercurial plaster or with yellow oxide of mercury salve or a 
piece of gauze. 

[An attempt to abort a boil by the accurate application of a solu- 
tion of iodin to its apex, repeated three times with twelve-hour 
intervals, should always be made at the inception of the process. It 
is useless when there is already a considerable induration. In cases 
of furunculosis every follicular inflammation, even the most insig- 
nificant, should be regarded as suspect and treated abortively. I 
agree with the author in condemning incision of a boil; it is bad 
practise, painful and useless. I earnestly recommend the following 
treatment: the affected area is washed with alcohol or 1 to 2000 
bichlorid alcohol. The boil is then covered with a 3 to 4 cm. square 
of salicylic acid plaster made according to the formula of Dr. 
Klotz: 1$ empl. diachyli 00.0, empl. saponis 25.0, cerse 2.0, vaselini 
8.0, acidi salicylici 5.0, M. ft empl. secundam artem. This plaster 
mass rolled in sticks for convenience is spread as required, smooth, 
even and thin on cotton-sheeting (muslin) and applied over the 
boil. It is soothing, protective and sufficiently occlusive while not 
adhering firmly enough to cause retention of pus. It should be 
removed twice a day, the free pus very gently squeezed out, the 
surface washed with a mild antiseptic and fresh plaster applied. In 



PYODERMATITIDES 543 

cases of furunculosis I employ the stock vaccines, four or five injec- 
tions at intervals of three to five days.] 

Internal treatment, with colloidal sulphur, sulphuric acid lemon- 
ade, sulphur compounds, hyposulphites, ichthyol, etc., is very 
variably estimated. Beer-yeast, preferably fresh, in doses of three 
tablespoonfuls daily, not infrequently produces a sudden subsidence 
of the inflammation and the pain. When it fails, beer-yeast from 
another source should be tried, or it may be replaced with a different 
ferment, for example a lactic ferment. 

In furunculosis the vaccine therapy of A. E. Wright, even with 
a stock vaccine of Staphylococcus aureus, constitutes an excellent 
although sometimes unreliable method of treatment. 

Care must of course be taken to correct the patient's hygiene; 
the dietetic regimen indicated in diabetes, auto-intoxication, arthri- 
tism, etc., may be called for in some cases. A cure at watering 
places with sulphur or arsenical springs is sometimes very useful in 
obstinate cases of furunculosis. 

Systematic treatment of furuncle, furunculosis and other staphy- 
lococcias with pure metallic powdered zinc mixed with zinc oxide, 
in doses of 4 to 8 grams daily, as recently introduced by Frouin and 
Gregoire, is extremely simple and sometimes seemed to be efficient 
in my experience. 

Carbunculus.— Carbuncle (French, anthrax) may be considered as 
an agglomeration of furuncles. The etiology is the same as that of 
furuncle. Garre successfully produced a carbuncle through inocu- 
lation of staphylococci derived from a case of osteomyelitis. 

The lesions are more extensive than those of furuncle; the necrosis 
of the perifollicular cellular tissue becomes confluent in large areas 
which are finally detached by the suppuration and appear no longer 
in form of circumscribed sloughs but under the aspect of sometimes 
very extensive gangrenous shreds. 

[The differences between carbuncle and furuncle are not simply 
a matter of degree. The phlegmonous inflammation in furuncle 
starting in a follicle always remains definitely circumscribed in a 
globular form, with the follicle as its center, though it may extend 
as far as the hypoderm. In carbuncle a similar infection extends 
into the hypoderm and then spreads to a greater or less extent 
laterally in the hypoderm ascending by the path of the columnae 
adiposes to the surface where it appears as a group of secondary 
furunculoid elevations in the neighborhood of the primary furuncle. 
A carbuncle is always a grave affection because it is capable of 
indefinite lateral extension in the hypoderm.] 

The onset is often marked by chills, malaise, general prostration, 
anorexia, while at the same time a very hard red swelling makes its 
appearance, which is the seat of severe tearing pain. The neighbor- 



544 INFECTIOUS DERMATOSES— PYODERMATITIDES 

ing edema is usually considerable and very extensive. At the end 
of lour or five days a few small vesicles or pustules manifest them- 
selves at the follicular orifices of the carbuncle; these become trans- 
formed into openings or craters from which pus escapes in increasing 
amounts and the grayish necrotic masses are subsequently evacu- 
ated. The skin between the orifices is purplish and swollen, often 
eroded; the bridges separating the orifices are often destroyed by 
purulent disintegration or necrosis. The openings of a carbuncle are 
accordingly multiple, irregular and winding. The period of evacua- 
tion lasts from a fortnight to a month. Spontaneous pain ceases as 
soon as the deep sloughing reaches its limit. Repair takes place by 
granulation; it leaves a very noticeable, often retracted and stellate 
cicatrix. 

In weakened patients, or in diabetics, etc., the woody indura- 
tion at the onset of a carbuncle may attain enormous proportions 
(woody phlegmon of the aged). In the period of suppuration, enor- 
mous winding cavities and purulent tracts are formed and sometimes 
large gangrenous patches. These diffuse or malignant carbuncles are 
accompanied by high fever, excitement, wild delirium or profound 
depression; they may lead to death through septicemia, hectic 
fever, or by rupture of large vessels or opening into large cavities. 

The prognosis, which is very variable, would seem to depend 
either on the virulence of the infection or on the character of the 
soil. The duration of a moderately severe carbuncle is from a 
month to six weeks. 

The treatment of benign carbuncle is patterned on the treatment 
of furuncle. Incision is rarely necessary or advisable. In large car- 
buncles, the introduction of sticks of Canquoin's paste (therapeutic 
notes, § 11) evidently shortens the total duration of the process. 
The treatment of malignant carbuncle belongs to the domain of 
surgery. 

Hidrosadenitis. — The hidrosadenitis of Verneuil, or tuberous 
abscesses of the axilla of Velpeau, are intradermic or subdermic 
abscesses, the size of an almond to that of a large nut or more, which 
occur exclusively in the axillary region. 

These abscesses are more common in women, developing espe- 
cially in cases of intertrigo, lack of cleanliness, hyperidrosis, but 
principally of axillary eczematides. 

One or more indurations develop, usually without general dis- 
turbances, with a sensation of pruritus, tension and distress. These 
indurations are perceptible on palpation, which is painful; gradu- 
ally they form a demonstrable, hemispherical, red, non-acuminate 
prominence. 

They may undergo absorption, but more frequently they soften 
and open through the thinned and reddened skin, emptying a 



PYODERM ATI TIDES 545 

creamy pus, but usually no slough. The development of each 
nodule lasts from ten to fifteen days; they succeed each other, some- 
times in both axillae, for weeks and months. The affection has a 
tendency to recur each summer. Complications are rare. 

On account of the differences in appearance and course, as well 
as the usual non-coincidence of these tuberous abscesses with fu- 
runcles in other regions, they are believed to be due to a staphy- 
lococcus infection of the [large axillary] sudoriparous glands rather 
than of the pilosebaceous follicles. 

The treatment is the same as that of furuncle. The hairs of the 
region should not be cut or shaved. I have known beer-yeast or 
various ferments work wonders in cases of protracted duration; the 
same remark applies to the modern treatment with zinc. Vaccine- 
therapy is also indicated and sometimes very successful. Scrupulous 
cleanliness is required to guard against recurrences. 



35 



CHAPTER XXVII. 
INFECTIOUS BACILLARY DERMATOSES. 

The infectious dermatoses caused by bacilli are: cutaneous tuber- 
culosis; leprosy, glanders, malignant pustule or anthrax, cutaneous 
diphtheria, soft chancre and probably also the verruga [Peruana] 
of Carrion and rhinoscleroma. 

A number of other affections have also been attributed to specific 
or non-specific bacilli, pure or associated, for instance, with spirilla 
(fuso-spirillary symbiosis), as follows: 

Wound-diphtheria and hospital gangrene, which belong to the 
domain of surgery; tropical phagedenic ulcer (p. 301, ulcero-mem- 
branous stomatitis (p. 306), noma (p. 308) and balanoposthitis 
erosiva circinata (p. 311). 

TUBERCULOSIS. 

The cutaneous manifestations of tuberculosis constitute at the 
present day an important chapter in dermatology. This chapter 
has only gradually been built-up and had no scientific basis before 
the discoveries of Villemin and Koch. 

Thus lupus vulgaris which had been distinguished from the other 
dermatoses by Willan and Bateman, was named tuberculous only 
because its characteristic lesion belongs to the class of tubercles, in 
the dermatological sense of this term. Clinicians — Lugol, Bazin, 
Hardy, Lallier, Vidal and Besnier- — grouped it among the scrofulides 
and more or less clearly surmised its tuberculous character. This 
was demonstrated histologically by Friedlander and others, experi- 
mentally by Max Schiiller, Leloir and especially by R. Koch. 

The evolution of our views in regard to the other types of cuta- 
neous tuberculosis has undergone analogous changes. 

Among the features on which a diagnosis of a cutaneous tuber- 
culosis is based at the present day, only two have a positive scien- 
tific value, namely : 

1. The presence of Koch's bacillus in the lesions. 

2. The positive outcome of inoculation of the affected tissue into 
animals, especially guinea-pigs which are sensitive to this infection. 

The other features permit merely a presumptive conclusion, 
although of considerable weight when several are present. Such 
features are: 

1. A histological structure in conformity with that of known 
tuberculous lesions. 



TUBERCULOSIS 547 

2. A positive local reaction to Koch's tuberculin A. 

3. A certain clinical appearance and course and special etiological 
factors. 

4. The coexistence of undoubtedly tuberculous manifestations. 
A serodiagnosis of tuberculosis unfortunately is not possible. 
Clinical Forms. — Five pathological types are known which in a 

general way satisfy these conditions and almost regularly present 
the six features enumerated above : Tuberculous ulcer, tuberculosis 
verrucosa, tuberculous gumma, fungoid tuberculosis and lupus vulgaris. 
I grouped these together under the generic heading of "cutaneous 
tuberculoses." 

The contributions of the last thirty years have shown that there 
exists in addition a considerable group of dermatoses which without 
usually fulfilling the first two conditions so frequently comply with 
the four latter as to justify the surmise of a close connection existing 
between them and tuberculosis. 

These dermatoses I have named tuberculides and the majority of 
modern authors interpret them, like myself, as attenuated tuber- 
culoses. It is only the limitations to be made to this group that is 
still a subject of discussion. 

It must be emphasized from the start that while this classification 
and these subdivisions are justified in the great majority of the 
cases and considerably facilitate their description and study, never- 
theless numerous transition forms are met with between the various 
types of cutaneous tuberculoses as well as between these and the 
tuberculides. The existence of transitions between the various 
manifestations of the same cause is in no way remarkable. 

General Etiology and Pathogenesis. — It would involve an encroach- 
ment upon the domain of general pathology to describe in this 
connection the Koch bacillus, to study its biological properties, 
its cultures, its secretions, its pathogenic properties in man and in 
animals, its portals of entry and the modifications apparently 
wrought in the course of the resulting disease through the properties 
of the affected territory. It is sufficient to emphasize the great 
extension of the field of tuberculosis through modern investigations. 
This infection at the present day appears to be infinitely more widely 
distributed than was formerly believed. 

It is in reality essentially an infection of childhood. When it 
attacks the newborn, which is rare, the patients almost invariably 
die. In the course of late childhood, the number of infected indi- 
viduals rapidly increases until, according to Naegeli, it reaches the 
proportion of 96 per cent, shortly after puberty. By no means all 
of these cases succumb to phthisis, meningitis or tuberculous septi- 
cemia; the majority resist the infection. When the initial lesions 
heal, various contingencies may arise : the tuberculosis may become 



548 INFECTIOUS BACILLARY DERMATOSES 

entirely latent, only the tuberculin reaction or possibly the autopsy 
being capable of revealing its existence. Or sometimes, so-called 
manifestations of local tuberculosis may persist or develop later on 
(glandular, bony, articular or cutaneous), constituting the " scrofula" 
of the older writers; furthermore recrudescences or the onset of new 
manifestations may occur at any time of life. 

The influences which determine the course taken by the tuber- 
culous infection are multiple and imperfectly known. One may 
incriminate the nature of the organic soil, the general hygienic 
conditions, the action of certain infections such as measles, etc., 
the effect of overwork, repeated pregnancies, etc., but the principal 
factor in recrudescences and in the development of new lesions 
undoubtedly is re-infection or superinfection of heterogenous or 
autogenous origin. 

It has been experimentally demonstrated, however, that the re- 
infection of an organism invaded by the tubercle bacillus does not 
produce the same effects as the first inoculation, but different effects; 
this is known as the allergy of von Pirquet. 

The subcutaneous inoculation of virulent Koch's bacilli into an 
animal of a very sensitive species, like the guinea-pig, produces at 
the end of ten or twenty days a nodosity which undergoes ulceration, 
/'. e., the tuberculous chancre; this is followed by glandular enlarge- 
ment, then regularly by a generalized visceral tuberculosis affecting 
chiefly the spleen and the liver, from which the animal dies. Experi- 
ments on monkeys, in Java, in 1905, under the direction of Xeisser, 
furnished practically identical results irrespective of the source of 
the tuberculous virus. 

When an already tuberculized guinea-pig is re-inoculated with 
bacilli at another point of the skin, preferably between four and six 
weeks after the first infection, the immediate result is an ecchymosis 
and a slough which falls off leaving a wound which heals without 
corresponding glandular enlargement; this is known as Koch's 
phenomenon ( L891 ) and constitutes a particular instance of allergy. 

In animals of more resistant species, this allergy manifests itself 
differently and the same is undoubtedly true for man. 

Returning to human cutaneous tuberculosis, with which alone 
we are here concerned, the following points must not be lost sight 
of: the individuals in which it is met with are practically all pre- 
viously infected with tubercle bacilli; the re-infecting agent may 
he of exogenous or autogenous origin, according as new bacilli come 
from the outside or from a focus of tuberculosis borne by the patient 
himself; in the latter case, the cutaneous re-infection may occur 
through contiguity (derived, for example, from a subjacent bony or 
glandular tuberculosis), or it may result from a metastasis through 
the lymphatic route or the blood route. 



TUBERCULOSIS 549 

These pathogenic conditions perhaps play a certain part in the 
diversity of aspect and course of the cutaneous lesions, although a 
smaller one than that pertaining to the existing state of allergy. 

The question has arisen as to whether the origin and strain of the 
bacillus may not be concerned in the production of these differences. 
The bovine bacillus has occasionally been found, in cases of lupus 
for instance, more often in London and New York than in Paris; 
but the human bacillus is usually responsible. Burnet has noted 
some instances of human bacilli of attenuated virulence in cutaneous 
lesions. Investigations of this question are still under way. 

At any rate, however, it must be admitted that although the 
reasons are not understood, tuberculosis of the skin manifests itself 
in lesions of very different form. 

I shall review the principal, most common and most definite of 
these lesions, noting that they have been arranged on a diminishing 
scale of clinical malignancy and bacillary content. 

Cutaneous Tuberculosis. — Tuberculous Ulcer. — This name is 
restricted to a primarily and essentially ulcerative lesion (p. 288) 
due to the Koch bacillus, which is abundantly present. This affec- 
tion has also received the names of miliary tuberculosis of the skin 
and mucous membranes; and acute tuberculous dermatitis. 

Ulcerated lupus, open tuberculous gumma, scrofula and fistulas 
derived from tuberculous osteitis, etc., do not fall under this defi- 
nition. 

It was in the mouth and notably on the tongue that tuberculous 
ulcer was first distinguished from analogous lesions by Ricord and 
subsequently studied by Julliard, Trelat, Fereol, etc. The observa- 
tions of Coyne, of Jarisch and Chiari, showed that it occurred also 
on the integument under an identical form. 

As a rule, tuberculous ulcer is observed only in already badly 
infected adults, notably in consumptives. 

It has two seats of election: in the mouth, on the lips, tongue, 
the inner aspect of the cheeks, the pharynx, or in the circumference 
of the mouth and nostrils; or at the anus and its surroundings. It 
is rare on the genital organs, but may be found there and give rise 
to serious difficulties in diagnosis. 

These localizations and the common preliminary of an open tuber- 
cular lesion of the lung, larynx, or intestines, in the same patient, 
are suggestive of the fact that tuberculous ulcer is generally refer- 
able to auto-inoculation of some fissure or erosion with bacilli from 
the sputum or the feces. 

Sometimes, however, it is the result of contagion. I have observed 
it on the forehead of an apparently healthy woman, the wife of a 
consumptive. Cases such as those reported by Lehmann, who saw 
ten healthy children become infected with tuberculous ulcers of 



550 INFECTIOUS BACILLARY DERMATOSES 

the penis by the mouth of a tuberculous rabbi, in the course of ritual 
circumcision, seem to me to be instances of primary tuberculous 
chancre, comparable to the chancre of newly inoculated guinea-pigs, 
but not tuberculous ulcers like those of consumptives. 

At the onset of a tuberculous ulcer, the lesion consists of one or 
several elevations of a dusky red color, which become lighter and 
finally evacuate their contents externally. The orifices become 
confluent and the ulcer extends rapidly on the surface, but slowly 
in depth. 

I have previously described its typical features in its fully de- 
veloped stage (page 288), a few of its most common clinical 
varieties, as well as the grounds on which the diagnosis rests; the 
reader is also referred to the description of atypical tuberculous 
ulcers elsewhere in this book (p. 291). 

Treatment. — In a consumptive patient, it suffices to touch the 
ulcer with camphorated naphthol, lactic acid, peroxide water, 
methylene-blue, or with a mixture containing iodoform; the pain 
must be controlled with cocain; if dressings are applicable, iodoform 
or one of its substitutes, dermatol, airol, europhen, etc., should be 
employed. 

If the patient does not appear to be tuberculous or only slightly so, 
the total removal of the lesion is indicated, or in default of this, 
scraping followed by cauterization with the thermocautery and 
appropriate dressings. 

Tuberculous Gummas. — These are subcutaneous nodes or nodosi- 
ties due to the Koch bacillus, which may be demonstrated in variable 
numbers. Their course tends toward softening and evacuation. 
They have been described elsewhere (p. 268). 

They are encountered preferably, but not exclusively, in patients 
in a bad general condition, suffering from visceral tuberculosis or 
especially from bony or glandular tuberculosis. Children and 
youthful individuals are more particularly susceptible. 

The treatment of tuberculous gummas varies according to their 
seat, their number and the general condition of the patient. When 
they can be extirpated surgically at an early date this is the most 
advisable procedure. Puncture followed by alterative injections 
rarely yields good results. When the gumma is open, it may be 
touched, after scraping if necessary, with iodin solution. Cam- 
phorated naphthol, iodoform-ether, guai'acol-oil, etc., followed by 
the application of dry or gomenol-oil dressings. 

Tuberculosis Verrucosa. — The term tuberculosis verrucosa, in ordi- 
nary use since the very complete investigations of this derma- 
tological type by Riehl and Paltauff in 1886, has replaced the terms 
verrucous scrofulide (Hardy, 1800), lupus verrucosus (MacCall 
Anderson, 1877) and sclerotic papillomatous lupus (Vidal and 



TUBERCULOSIS 



551 



Leloir, 1882), which more or less closely corresponded to it. The 
condition was very thoroughly discussed by H. Moutot, in his 
These de Lyon, 1907 (Fig. 167). 

Elsewhere in this book I have recorded the clinical description 
of the lesions and pointed out their usual site (page 247). The 
patches are sometimes multiple. 

Tuberculosis verrucosa results in the great majority of the cases 
from an external inoculation. 

It is observed in consumptives as the result of auto-inoculation of 
their sputum or dejecta; on the other hand, in nurses, butchers and 
veterinaries, who through their occupation come in contact with 
tuberculous individuals, human or animal. It may be derived from 
an auto-infection of the skin by a focus of bony, articular, or 
tendinous tuberculosis. Tuberculous lymphangitis, which usually 




Fig. 167. — Tuberculosis cutis verrucosa. 



assumes a gummous or fungoid type, sometimes presents a verrucous 
character. A few scanty Koch's bacilli may be found in the sections; 
guinea-pig inoculation is usually positive. Some authors believe 
that tuberculosis verrucosa is due especially to a bovine bacillus; 
according to others, a human bacillus is more commonly demon- 
strable. 

The onset, which usually escapes notice, is in the form of a small, 
hard, horny nodule which frequently suppurates and becomes an 
abscess. The development of the lesions is centrifugal or serpiginous. 

Lupus tubercles are never demonstrable in the developed stage, 
but I have noted their appearance in the subsequent cicatrix. 

The duration is very protracted and indefinite. The patch may 
become partially cicatrized, but a complete spontaneous cure is rare. 
Tuberculosis verrucosa may lead to lymphatic propagation and 
visceral generalization; it accordingly constitutes a serious lesion. 



552 INFECTIOUS BACILLARY DERMATOSES 

Anatomical Tubercle or verruca necrogenica — described by 
Laennec, is merely a particular instance of tuberculosis verrucosa. 
Jt is encountered among medical students, physicians, dissecting- 
room attendants and nurses; its more rapid course is undoubtedly 
explained by mixed infect ion. As early as the day following the 
local infection, through a puncture or contaminated erosion, a 
painful erythema makes its appearance, followed by the formation 
of an elevated dermic pustule. In spite of application of various 
topical agents, the elevation persists, becomes indurated and gradu- 
ally extends through the confluence of neighboring small pustules. 
The lesion promptly assumes the appearance of a horny papilloma 
or a hard tubercle covered by a crust; it is surrounded by a purplish- 
red halo; it i> painful on pressure. The mixed tuberculous and 
pyococcic infection may extend deeply, reaching the lymph channels 
and glands of the elbow and the axilla, causing suppurative adenitis 
and ultimately a visceral tuberculosis. 

Treatment of Tuberculosis Verrucosa. — This must be early, rapid 
and energetic. The method of choice is surgical excision, when this 
is possible. In default of excision, excellent results are obtained by 
thorough scraping, under local anesthesia, followed by two or three 
radiotherapeutic sessions during the cicatrization. Z-rays or radium 
employed alone are not to be recommended. Strong caustic agents, 
Vienna paste, Unna's white caustic paste, carbonic acid snow or 
superheated air, may also be employed in certain cases. The cicatrix 
must always be watched, as relapses are likely to occur. 

Fungoid and Vegetative Tuberculosis. — In addition to tuberculosis 
verrucosa and lupus tumidus or vegetans, a less common form is 
observed, which is entitled to the name of fungoid tuberculosis, 
proposed by Riehl in 1894. 

It presents the appearance, either of a very soft, irregular and 
[obulated red tumor, or of a flabby, distinctly outlined, mammillated 
and prominent patch. Its surface may be ulcerated, crusted or 
partly cicatrized. 

It seems to result sometimes from an exogenous inoculation, in 
other cases from an auto-infection of the skin derived from a bony, 
articular or glandular focus. It is met especially on the limbs, but 
also on the trunk and even on the face. The differential diagnosis 
from mycosis fungoides, epithelioma, sarcoma, blastomycosis, sporo- 
trichosis etc., may present serious difficulties, but these can be 
overcome by the histological examination, bacteriological findings 
and animal inoculation. 

The following may be considered as varieties of the above form: 
Tuberculosis frambcesiformis composed of large, soft and extensive 
papillomatous patches, occupying especially the perigenital regions; 
it was described by Doutrelepont, Wickham, Hallopeau, Jessner, 



TUBERCULOSIS 



553 



etc.; also the tuberculosis fungosa serpiginosa of Jadassohn; further- 
more, certain tuberculous lymphangitides (fungoid lymphangitic 
tuberculosis) studied by Bazin, A. Fournier, Morel Lavallee, et al. 
In the last-named variety, which closely resembles the lymphan- 
gitic form of sporotrichosis (Fig. 180), a series of lesions are found 
arranged in succession along the course of lymphatic vessels coming 
from a tuberculous focus; these lesions may be fungoid or in other 
cases gummous or verrucous; sometimes a subcutaneous, nodular 
strand connects the various foci with each other. Hallopeau and 
Goupil described a lymphangiectasia variety, in which the tuber- 
culous infiltration is complicated by lymphatic varicosities; it may 
lead to secondary elephantiasis. 

The treatment of the fungoid tuberculoses must consist in scraping 
and cauterization. Radiotherapy may render valuable accessory 
services. 




Fig. 168. — Lupus vulgaris (agminatus, tumidus, non-exedens) with central sclerosis 
and centrifugal extension. 



Lupus Vulgaris. — Lupus — lupus vulgaris, tuberculosis luposa, 
Willan's lupus — owes its traditional name to the ulcerative, gnaw- 
ing, devouring tendency frequently assumed by it. It represents 
the most common as well as the most polymorphous and most 
obstinate form of all cutaneous tuberculoses. 

Lupus vulgaris is characterized by its eruptive lesion, the lupus 
tubercle or lupoma (page 256). 

It is situated, as previously stated, on the face and neck in the 
great majority of the cases, especially at the nose or on the cheeks; 
more rarely on the limbs or on the trunk. 

Varieties. — Lupus may assume extremely varied appearances. 
Such a large number of varieties have been described by authors 



554 INFECTIOUS BACILLARY DERMATOSES 

that one is often at a loss as to where to group a given case. Famili- 
arity with at least the principal forms seems essential. 

Three types of lupus are distinguished according to the distribu- 
tion of the lupus tubercles: 

Lit pits disseminatus, in which isolated or sometimes very numer- 
ous ] lipomas are spread over one or more regions of the body; it 
usually occurs as a sequel of infectious diseases, especially measles; 
it closely resembles cutaneous sarcoid or lupoid. 

Lupus agminatus is the most common form; the grouped tubercles 
become confluent in the center of the patch as a disk or plaque and 
are scattered in the circumference (Fig. 168). 

l/upus diffusus or confluens consists of an often prominent, soft, 
nodular patch, of a purplish, yellowish or brownish-red color, with 
rounded, oval or irregular contours; the lupus tubercles are confluent 
and indistinguishable. 

The degree of prominence of the lupus permits a differentiation 
between the following forms: 

Lupus Planus. — This comprises numerous varieties, macular, 
squamous, psoriatiform, erythematoid and colloid, which are suffi- 
ciently characterized by their designation. Lupus planus is 
usually of the agminated type. 

Lupus Tumidus or Lupus Elevatus. — This form, which is more 
common than the preceding, likewise presents varieties: colloid, 
myxomatous, etc. 

Lupus Hypertrophicus. — An angiomatous variety has been 
described; a papillomatous variety which practically blends with 
tuberculosis verrucosa; and an elephantiastic variety which affects 
the limbs especially. 

The configuration of a lupus patch is of interest only in so far as 
it is connected with the course of the affection. Discoid, corymbi- 
form, marginate, circinate, centrifugal, serpiginous, linear, annular 
and other configurations have been described. 

The developmental tendency of a given lupus is the most impor- 
tant of all its features. Raver and Devergie already recognized 
the existence of two great classes from this point of view. 

1. Lupus nou-exedens, which does not ulcerate and manifests 
itself in type, form and configuration under one of the numerous 
varieties enumerated above. It grows slowly, continuously or 
intermittently. 

It not infrequently becomes transformed into a cicatrix at its 
center; but a recurrent growth of the lupomas in the sclerotic 
tissue is far from uncommon. When spontaneous total cicatriza- 
tion occurs, as in lupus planus and even in lupus tumidus, the 
condition is described as scleroticus or resolutus. 

The erythematoid variety of lupus planus, also known as ery- 



TUBERCULOSIS 555 

themato-tuberculous lupus of Vidal and Leloir, was considered by 
the last-named author as a combination of Willan's lupus with the 
lupus erythematodes of Cazenave. It gives rise to frequent errors 
in diagnosis. This is really a superficial tuberculous lupus, as 
properly recognized by Dubreuilh; the lupomata are small, sub- 
epidermic, sometimes confluent and not readily perceptible to the 
unaided eye; but they are distinctly revealed on biopsy. In this 
variety of lupus, which may invade the nose and the cheeks in the 
form of a butterfly, there is a pronounced tendency to spontaneous 
cure; it is of the resolutive type. 

A lupus non-exedens may at any moment of its course become 
erosive, ulcerative and even mutilating; so that there is no essential 
difference between this class of lupus and the following: 

2. Lupus exedens, or primarily ulcerative lupus, often takes a 
violent and rapid course; its exuberant proliferation, its active 
growth, its relatively rapid extension and the final partial disin- 
tegration undergone by it, lead to early destruction and mutilation. 
It assumes one of the following clinical forms : 

Pustular lupus consists of soft elevations the size of a cherry 
pit, which have a tendency to become confluent and which in less 
than a month open like abscesses. 

Ulcerative vegetative lupus is composed of soft fungoid infiltra- 
tions, producing for instance the appearance of a tomato, into which 
sharp instruments will cut as into butter; the ulceration which 
results from the breaking-down of the newformation, leads to fear- 
ful mutilations of the nose, the lips, the velum of the palate, the 
eyelids, etc. It is described as lupus vorax or lupus phagedenicus 
when its course is especially rapid. 

Serpiginous tuberculo-ulcerative lupus, which may precede or 
follow a lupus non-exedens, is seen on the trunk and the limbs even 
more often than on the face and, like erythematoid lupus, prefer- 
ably in aged individuals; it consists of a central cicatrix bordered 
by large pustular crusted, sometimes rupioid, lupus tubercles. It 
closely resembles the ulcerative-serpiginous syphilides and although 
its course is slower it may periodically progress very rapidly. 

The varieties of lupus most commonly met with are, briefly: 
lupus planus agminatus, with a tendency toward central cicatriza- 
tion; lupus tumidus agminatus in patches, level or protuberant; 
and tuberculo-crusted or tuberculo-ulcerative lupus serpiginosus . 

It is extremely common for a lupus which has not been treated 
or even dressed to present itself covered with yellowish or brown- 
ish crusts; in such cases it is impossible at the first examination 
and before it has been cleansed to determine the variety to which 
it belongs. The formation of the crusts and of the erosions con- 
cealed by them is undoubtedly referable in part to a pyodermic 



>56 



INFECTIOUS BACILLARY DER WATOSES 



complication. Lupus which is thus disfigured is ordinarily called 
impetiginous lupus I Fig. 169). 

All these morphological varieties really possess only a didactic 
and diagnostic value. Lupus vulgaris is single in character and 
may very readily assume a variable appearance and behavior at 
different points or different times. 

Etiology. Topography. Lupus may appear at any age, but in 
more than one-half of the cases it manifests itself before the fifteenth 
and rarely after the thirtieth year. It is more common in the 
female sex and in Northern countries. A certain family predispo- 




Fig 101). — Lupus Lmpetiginosus with multiple foci, showing tin- points of inocula- 
tion of the skin. The infection probably occurred through the nostrils and the nasal 
fossa', reaching the nose and the cheek directly; attaining the internal angle of the 
eye through the lachrymal duct; the submaxillary region by way of the glands; a 
U-w of the latter were extirpated, as indicated by the keloid cicatrix under the ear; 
the other glands suppurated and opened on the skin. 



sit ion seems to play a part; A. Ollivier mentions the ease of a family 
of five children, four of whom had lupus. Very frequently an 
apparent tuberculosis is found in the ascendants or collaterals; 
however, as pointed out by Besnier, consumptives do not acquire 
lupus, whereas lupus patients very frequently develop pulmonary 
tuberculosis. 

[All forms of lupus and especially the highly destructive forms 
are rare in America as contracted with their frequency in European 
countries. The high daily average of sunlight throughout North 
America may possibly play a role in this relative freedom, hut on 



TUBERCULOSIS 557 

the other hand, lupus is common in sunny Italy. It seems more 
probable in view of the fact that lupus is preeminently a disease of 
the poor, that the better nourishment of the poorer classes in 
America is the important factor.] 

Lupus attacks principally, although not exclusively, individuals 
of a scrofulous habitus, with thick, soft flesh, a pale or florid com- 
plexion, swollen nose and lips, acro-asphyxia, frost-bite, chronic- 
glandular enlargements and a readily vulnerable skin; in scrofulous 
women, the ear-lobes are often cut by the wearing of ear-rings. 
This classical scrofula is now known to correspond, not to a soil 
merely susceptible to the bacillus, but rather to an accomplished 
but attenuated and latent bacillary infection. Lupus accordingly 
seems to result from a local superinfection of autogenous or exog- 
enous origin, in an individual in a state of allergy. 

In the tissues of lupus, bacilli are very rare and dozens of sections 
must be examined before one is found. They have been assumed 
to be of a special strain or attenuated virulence, which would agree 
with the slow course of lupus. According to recent findings, the 
condition is more frequently due to the human than to the bovine 
bacillus; as to its virulence, the following statements can be made: 
Inoculation of lupus tissue, correctly grafted into the guinea-pig's 
peritoneum, gives rise, as a rule, to ordinary tuberculosis, trans- 
missible to a series of animals; however, in my experience, the 
inoculation is unsuccessful in over one-third of the cases. Pau- 
trier, who inoculated neighboring fragments of the same lupus into 
guinea-pigs, obtained, in the same series, sometimes positive and 
sometimes negative results. Whatever may be the explanation of 
these cases, it seems to me that in combination with the clinical 
data, they justify the interpretation of lupus as a relatively slightly 
virulent form of cutaneous tuberculosis and even as an intermediate 
pathological type between the true cutaneous tuberculoses and the 
tuberculides. 

The portal of entry of the local infection which causes lupus is 
external or internal. The possibility of its resulting from an 
accidental inoculation of exogenous origin is attested by authentic 
cases in which a lupus has been seen to supervene in an apparently 
healthy person, following upon a wound, perforation of the ear 
lobules, vaccination, etc. Perhaps the ordinary impetigo of chil- 
dren may serve as an avenue of entrance. The frequency of lupus 
on the nose or in its vicinity is accounted for by the infection of 
the nasal fossae through the dust inhaled in respiration or by contact 
with the fingers. As a matter of fact, four-fifths of lupus lesions 
are situated on the face (Fig. 169). 

On the other hand, the origin of the superinfection may be autog- 
enous and the inoculation of the skin take place from within out- 



558 INFECTIOUS BACILLARY DERMATOSES 

ward as in case of lupus following upon broken-down glands, of 
common occurrence in the neck; or upon tuberculous osteitis, as seen 
on the limbs. Lupus of the cheek may be due to a tuberculous 
lymphangitis derived from the nasal fossse. 

Cases in which the bacillus arrives from some internal focus by 
way of the vascular system are more numerous than is usually 
assumed. Disseminated lupus lesions are evidently produced by 
this means, favored especially by a temporary loss of body resist- 
ance under the influence of measles, grippe, pregnancy, etc. 

On the genital organs, lupus is rare; in women, it has been con- 
fused with esthiomene. At the circumference of the anus, lupus is 
often combined with papillomatous tuberculosis or tuberculous ulcer- 
ations and results from an auto-inoculation with bacilli contained 
in the dejecta. 

The palmar and plantar regions and, to a certain degree, the 
trunk but very particularly the scalp, are endowed with a relative 
immunity toward lupus. 

Lupus of the mucous membranes is encountered in one-third of 
the cases, but must be looked for. I have pointed out that the 
initial focus is frequently nasal. Often soft elevations are observed 
on the anterior portion of the septum leading to perforation of the 
latter. From here, propagation takes place to the eyelids through 
the lachrymal passages, but the conjunctiva usually escapes; or 
to the palate and gums, through the anterior palatine foramen, 
and more frequently, to the velum of the palate and to the pharynx. 

In the throat, in the mouth and the larynx, lupus usually assumes 
the appearance of a pinkish mammillated surface interspersed with 
ulcerations; on the gums, that of a crop of soft red fleshy prolifera- 
tions; on the tongue it is very rare and almost invariably assumes 
a papillomatous form, although I have seen a lupus ulcer of the 
tongue. 

In a general way, although lupus of the mucous membranes 
belongs to different varieties and although no lupomata of a barley- 
sugar appearance are here demonstrable, its course and the usual 
coexistence of lupus of the skin serve to facilitate its diagnosis. 

Course and Complications. — The long duration of lupus and its 
rebellious character are its most essential features. Lupus per- 
sisting for ten or twenty years is very common. Feulard reported a 
case of sixty-eight years' standing. 

Its ulcerative forms, but also up to a certain point those with a 
tendency to cicatrization, lead to deformities and truly hideous 
mutilations; ectropion, complete destruction of the nose with 
stricture or even atresia of the nostrils, buccal atresia, vicious and 
keloid cicatrices and transformation of the extremities into mis- 
shapen stumps (Fig. 170) are not uncommon. 



TUBERCULOSIS 559 

The course of lupus may be interrupted by congestive, edematous 
or suppurative exacerbations. 

Recurrent lymphangitis seems to play a part in the elephanti- 
astic form. Erysipelas , considered as favorable by some authors, 
appeared rather injurious in the majority of cases. Corresponding 
glandular enlargement or adenopathy is rather common although 
not constant. 

Pulmonary and visceral tuberculosis is responsible for a large 
number of deaths among lupus patients, although it usually takes 
a slow and protracted course in these cases. Many patients 
affected with lupus otherwise enjoy excellent health. I have seen 
several who were married and had a healthy progeny. 




Fig. 170. — Lupus mutilans of the hand. 

Epithelioma is a formidable complication of lupus, on account 
of its rapidly invasive course. Its frequency has been estimated 
at 4 per cent, of the cases. The onset of cancer is recognized by the 
changed appearance of an area of the lupus eruption, where a 
hard painful proliferation arises and promptly ulcerates or under- 
goes partial necrosis; biopsy is often required to confirm the diag- 
nosis. 

Tertiary or congenital syphilis has been charged with creating a 
predisposition to lupus; a possible association has even been sus- 
pected on the basis of the sometimes very favorable although 
incomplete effects of mercurial treatment in some cases of lupus. 

Diagnosis. — The differentiation of lupus from tubercular 
or tuberculo-ulcerative tertiary syphilides is most frequently 
demanded. The course and the age of the lesions sometimes 



560 INFECTIOUS BACILLARY DERMATOSES 

furnish presumptive evidence; actually, leaving aside lupus exe- 
dens, it may be stated that lupus requires years to accomplish 
what syphilis will do in a few weeks or months. The softness, 
the yellow translucid color of the lupus nodule and its renewed 
growth in the cicatrix, are characteristic of lupus. However, 
certain syphilides are "lupoid" to such a degree, even on histo- 
logical examination, that the question can be settled only by means 
of the Wassermann reaction and guinea-pig inoculation; the local 
tuberculin reaction also possesses a real value. 

The color, the opacity, the elastic consistence and the anesthesia 
of the tubercles of leprosy are sufficiently characteristic to guard 
against error; all doubts will be removed by a general examination 
of the patient. 

The confusion of lupus with eczema, impetigo or psoriasis is 
inexcusable, although it may assume the objective appearance of 
an impetiginous or psoriatiform eruption. 

The lupoid sycosis of Brocq affects only the hairy regions, is 
distinctly cicatricial in the center and bordered by suppurating 
folliculitis. 

The differentiation may prove very difficult between lupus dis- 
seminata and the sarcoid of Boeck, which I have described under 
the name of disseminated miliary lupoid; histological examina- 
tion and guinea-pig inoculation furnish the only reliable criteria. 
The boundaries between various forms of lupus and tuberculosis 
verrucosa, or tuberculosis fungoides and its varieties, are indefi- 
nite, so that well-informed dermatologists will group under one of 
these headings cases which by others are considered as lupus; 
at any rate, these dermatoses are of the same nature. 

What I shall have to say further on in regard to lupus erythema- 
todes, actinomycosis, the blastomycosis, the leishmanioses, etc., 
will probably suffice to permit the diagnosis of these affections. 

The tuberculin test with Koch's tuberculin A, in subcutaneous 
injection, when it produces a positive local reaction to a minimum 
dose possesses real value not only for the recognition of lupus but 
for the determination of its clinically undemonstrable extent. The 
cuti-reaction of von Pirquet with crude tuberculin or Morn's 
procedure which consists in the comparative rubbing of a small 
lupus surface and a surface of healthy skin with tuberculin incor- 
porated in lanolin, equal parts, may also be utilized. 

Lupus of the mucous membranes may simulate very different 
affections; usually the coexistence of lupus of the skin is of great 
help. In primary cases, the differential diagnosis from focal 
syphilomata and from papillary epithelioma is extremely difficult; 
the differential features may be insufficient and biopsy as well as 
serodiagnosis become indispensable. 



TUBERCULOSIS 561 

Treatment. — I shall refrain from entering into details on this 
inexhaustible topic, restricting myself to practical suggestions. 
It is evident that the seat, the extent of the lesions, the age, the 
social condition and the general health of the patient must influ- 
ence the choice of the therapeutic method. 

When- a lupus is operable without mutilation, the preference 
must be accorded to surgical removal, with or without autoplas- 
tics; the tuberculin test should first be carried out in order to 
recognize its actual limits, following the advice of Neisser and Kling- 
miiller. Extirpation should accordingly be the method of choice 
in lupus of the limbs, the trunk, the neck, unless it is too extensive. 

Curettage, if necessary under anesthesia, may yield rapid but 
unreliable results, only mediocre from the cosmetic point of view; 
in all cases, this treatment should be combined with cauterization 
by the actual cautery or caustic agents, carefully watching the 
cicatrization, during which radiotherapy may usefully be employed. 

Total destruction through cauterization (thermocautery, galvano- 
cautery, superheated air) or through chemical caustics (such as 
trichloride of antimony, trichloracetic and hydrochloric acids, etc.) 
is open to the same objections. 

Abroad, pyrogallol is freely used as a salve (from 5 to 20 per 
cent.) but it is very painful; the green salve of Unna (see Thera- 
peutic Notes) seemed preferable to me. 

Most frequently, graduated progressive methods together with 
physical agents should be resorted to, thereby stimulating or favor- 
ing the sclerotic process adopted by nature in cases of spontaneous 
cure. 

Crossed linear scarifications would constitute an excellent cura- 
tive procedure, in view of the qualities of the resulting cicatrix, but 
for the often considerable and even endless number of sessions 
required for this treatment. Nevertheless, scarifications are impera- 
tive in case of vegetative lupus or lupus vorax, which they control 
with remarkable rapidity; in lupus of the orifices of the face; and 
for the correction of lupus cicatrices with a persistent crop of 
tubercles. 

Ignipuncture with the galvanocautery does not aim at the 
total destruction of the lupus, but like scarification tends to pro- 
duce centers of cicatrization which, multiplied by later sessions, 
lead to confluence. This is a most valuable procedure for the 
reason that it is inexpensive, more rapid than scarification, easily 
applicable, particularly adapted to cases of lupus already modified 
by previous treatment and especially unrivalled in lupus of the 
mucous membranes. 

As adjuvants of the preceding methods, or even sometimes 
exclusively, according to some authors, medicinal topical agents 



662 INFECTIOUS BACILLARY DERMATOSES 

have been recommended and may prove highly advantageous; I 
shall quote only potassium permanganate in strong solution or 
even in substance, pyrogallol, resorcin and especially mercurials in 
the form of plasters. 

The introduction of new physical methods has partly transformed 
and certainly improved the traditional therapy of lupus. 

The phototherapy of FinseD undoubtedly yields the best cos- 
metic results, moreover without pain; on the other hand, it is 
open to serious objections on account of the considerable number 
of sessions required (200 to 300 for a lupus of moderate extent), 
the very high cost of the apparatus and the sessions, as well as 
the failures, the proportion of which is not inconsiderable. The 
mercury vapor quartz lamp is more convenient and less expensive. 

Radiotherapy and radiumtherapy have not entirely justified 
the expectations placed upon them. Their indication and their 
mode of employment in lupus are still a matter of controversy. 
However, the majority of authors are agreed in the repudiation 
of destructive doses which involve the risk of sometimes tardy but 
always formidable radiodermatitis. Injudicious repetition of the 
sessions involves the same dangers. In moderate doses, the radia- 
tions are very efficient in fungoid or papillomatous lupus and in 
superficially ulcerated lupus lesions. But the x-rays are especi- 
ally to be recommended as adjuvants and I may say that at the 
present writing, galvanopuncture or periodical scarifications fol- 
lowed by radiotherapy in cautious dosage, seem to constitute the 
best treatment of lupus not amenable to surgical extirpation. 
Radium should be accorded the preference in cases of lupus of the 
mucous membranes or lesions difficult of access. 

Internal treatment alone must never be relied on for the cure of a 
lupus, but there is often reason for and marked benefit to be expected 
from medication with calcium, arsenic, cod-liver oil and iodides; as 
well as from a sojourn in suitable watering-places by the seaside 
or on high mountains. This climatotherapy may be combined with 
heliotherapy, which is very beneficial when properly employed. 

Among the various hypodermic injections which have been 
advocated, notably cacodylates, cantheridin, nuclein, thiosinamin, 
etc., in my opinion calomel injections are the only ones which can 
sometimes be recommended. When applied as in the treatment 
of syphilis, they are capable of producing remarkable improve- 
ment, but are found to be very unreliable; on the other hand, 
systematic injections, in gradually increased doses, of Koch's tuber- 
culin A, which I have resumed after many other trials, have some- 
times yielded remarkably rapid favorable results in my experience; 
great caution is required in their use. 

The treatment of lupus needs insight, considerable patience and 



TUBERCULOSIS 563 

skill in the variation and combination of the methods best adapted 
to the individual case as well as indefatigable perseverance in the 
management of partial relapses. A cure cannot be considered as 
practically certain until several years have elapsed after the dis- 
appearance of the visible lesions. 

Tuberculides. — Since my suggestion in 1896 a number of appar- 
ently very dissimilar dermatoses have been grouped under this 
heading, whose relations with tuberculosis are proved by the follow- 
ing features. 

The tuberculides themselves are frequently associated in the 
same individual and very often coexistent with glandular, bony, 
serous, visceral or cutaneous tuberculous manifestations; or the 
patients have a tuberculous history, or are found to be tuberculous 
later on. 

The histological structure of the tuberculides is sometimes 
typically tubercular and identical with that of the most positive 
tuberculoses; in other cases it is non-tubercular, inflammatory and 
necrotic; but this is now known to be the case even in certain 
undoubtedly bacillary tuberculoses. 

As a rule, no Koch's bacilli are found in the tuberculides; how- 
ever, several authors report their discovery by means of the 
improved methods of Much-Gram, with antiformin, etc. Inocu- 
lation of their tissue into guinea-pigs is usually negative; but 
exceptions to this rule have occurred, diminishing the demon- 
strative value of the usual negative findings. Furthermore, it is 
noteworthy that Gougerot experimentally produced analogous 
lesions, which he regards as identical with tuberculides, by rubbing 
pure cultures of Koch's bacilli on the shaved skin of the guinea- 

Pig- 

The tuberculin test is often, but not invariably, positive in the 
tuberculides. 

From the point of view of their clinical course, the tuberculides 
in general are distinguished from the cutaneous tuberculoses by 
their usual occurrence in a disseminated form, which is less com- 
mon in the latter; and moreover by their marked tendency to 
spontaneous cure. 

They appear in successive crops, without fever, without dis- 
turbance of the general condition; they often have a symmetrical 
distribution and a variable but rather prolonged duration. The 
various forms have a marked predilection for certain periods of life 
and for certain regions which are predominantly affected. 

Clinical Forms. — As nearly all the forms of tuberculides were 
observed and described before their real nature was suspected, 
the names they bear are based on their morphological appearance, 
so that their nomenclature is a regular Joseph's coat. To bring 



564 INFECTIOUS BACILLARY DERMATOSES 

some order into this disorder, I recommend the following classifi- 
cation : 

A. Cutaneous Tuberculides. — The seat of the lesions is dermo- 
epidermic in the following forms: 

1. Lichenoid tulwrculides (lichen scrofulosorum and lichen nitidus 
— these forms have already been sufficiently described (pp. 146, 
138). I have seen also a few rare cases which simulated patches 
of lichen planus. 

'2. Papulonecrotic tuberculides (folliclis and acnitis of Barthelemy). 

3. Acneiform tuberculides (acne cachecticorum of Hebra) — this is 
simply a variety of the preceding form. 

4. Lupoid tuberculides (benign sarcoids or lupoids of Boeck 
(p. 259). 

5. Erythemato-atrophic tuberculides (lupus erythematodes of Caze- 
nave and certain atrophodermas). 

6. Erythematous tuberculides (lupus erythematodes exanthema- 
ticus). 

B. Hypodermic Tuberculides. — Three principal types have been 
described: the erythema induratum of Bazin, the subcutaneous 
sarcoids of Parier-Roussy and the disseminated nodular sarcoids; 
in all probability these are simply varieties of the same species 
(p. 272). Certain scrofulous gummas of attenuated virulence 
(p. 268) and a few atypical tuberculous ulcers (p. 291) are 
evidently related to this group. 

C. Doubtful Tuberculides. — It is necessary to point out in this 
connection a certain number of affections whose relations with 
tuberculosis are emphasized by some authors but denied by others; 
these relations are problematical or perhaps indirect. Such con- 
ditions are: 

Certain forms of frost-bite (pernio tuberculides) (p. 34). 
Piti/riasis rubra of Hebra-Jadassohn (erythrodermic tuberculide) 

<P- li8) / 
Certain forms of parapsoriasis (parapsoriatic tuberculides?) 

(p. 111). 

Pityriasis rubra pilaris (erythrodermic perifollicular tuberculide?) 
(p. 399). 

Perhaps certain cases of eczema folliculorum of Malcolm Morris 
and a few other authors (eczematoid tuberculides?) (p. 396). 

Perhaps also angiokeratoma (angiokeratotic tuberculides) (p. 
695). 

This enumeration, lengthy as it is, does not exhaust the subject. 
As a matter of fact, only the relatively common and fairly well- 
established clinical types have so far been described under a special 
name. There exist more rare types as well as some with mixed 
features and transition forms as yet unclassifiable. I have seen 



TUBERCULOSIS 565 

cases, for example, which might have been indifferently diagnosed 
as lupus pernio or folliclis or lupus erythematodes; all that could 
be stated was that the case was one of tuberculide. One would 
naturally hesitate to lay down exact rules for unique cases or for 
transition forms which are of exceptional occurrence. 

Nature and Pathogenesis. — According to their mental proclivities, 
authors have conceived a different and even contradictory inter- 
pretation of the nature of these dermatoses. In the opinion of 
some, their relations with tuberculosis were extremely doubtful. 
Tuberculosis, they said, is a disease so widely distributed that its 
presence in a patient or his environment is irrelevant. The course 
of the tuberculides, the absence of really scientific proofs of their 
bacillary origin, justify neither their arbitrary grouping with the 
legitimate tuberculoses nor the assumption of their kinship with 
them. 

Others, on the contrary, regarded the tuberculous nature of these 
affections as so unquestionable that it was actually proposed to 
abandon the provisional term of tuberculides and to incorporate 
this group among the cutaneous tuberculoses, of which they were sup- 
posed to represent still more attenuated types than lupus vulgaris, 
for example. The dissemination and customary symmetry of tuber- 
culide eruptions were explained as due to the virus having travelled 
by the vascular route. With reference to the attenuated virulence 
of the lesions, various interpretations were suggested. The theory 
of Hallopeau, according to which the tuberculides are dependent, 
not on the bacilli themselves, but on their soluble toxins (toxi- 
tuberculides) met with many objections. The interpretation of 
Haury appeared much more probable; in his opinion the tubercu- 
lides result from embolisms of dead or attenuated bacilli, perhaps 
due to the struggle they had undergone against the defensive forces 
of the organism in a primary glandular or other infectious focus 
or in the blood current. These bacilli arrive in the skin while still 
capable of exciting a temporary local reaction and even small 
necrotic foci; but they succumb or disappear more or less rapidly — 
hence the spontaneous cure and non-inoculability of the lesions. 

By applying to the interpretation of the tuberculides the preva- 
lent view of tuberculous infection, their pathogenesis becomes con- 
siderably clearer. Tuberculosis is an almost universal infection; 
it heals very often to the point of becoming clinically latent; but it 
remains nevertheless capable of reviving under various influences 
and of giving rise to a discharge of bacilli; it creates a state of 
relative immunity which manifests itself by the phenomena of 
allergy. It thus becomes intelligible that the cutaneous manifes- 
tations resulting from bacillary embolisms may vary greatly in 
form and behavior, according to the degree of attenuation of the 



566 tNFECTIOUS BACILLARY DERMATOSES 

bacilli, according to the Dumber of imported bacilli, as well as 
according to the degree and kind of allergy enjoyed by the indi- 
vidual. But these incomplete data and speculations still require 
definite scientific confirmation. 

Papulonecrotic Tuberculides. This clinical form was first described 
under the name of lupus erythewaforfe* rfisxcniiiKitiix (Boeck, 1880), 
then as cicatricial folliculitis of the hairless part* (Brocq), as fob- 
liclis and aortitis (Barthelemy) [as hydradenitis destruens suppurativa 
(Pollitzer)], as hidrosadenitis suppurativa disseminata (Dubreuilh); 
Kaposi called it acne telangiectodes. 

It is not very rare and occur- especially in adolescents and young 
adults. 

The eruption, consisting of a very variable number of lesions, 
appears in successive crops. It occupies preferably the hands and 
the fingers, the forearms (Fig. 171), the elbows, the circumference 
of the knees, the feet, the face, the ears and not infrequently also 
the trunk. 




Fig. 171. — Papulonecrotic tuberculides. In this patienl the eruption occurred on 
t lie* four extremities. 

The typical lesions begin as a very minute dull-red elevation, 
which on palpation reveals a hard painless nodule, the size of a 
pin-head, more or le>s deeply imbedded in the cutis; in about a 
week, this nodnle becomes raised, its surface turns livid and pur- 
plish, while an epidermic vesico-pnstule appears at its summit. 
When this is opened with a pin, only a very small amount of turbid 
serum escapes, and a sharp-bordered depression with a grayish 
floor appears in the cutis. Left unopened, the lesions become 
transformed into crusts which are not shed till after two to four 
weeks and leave distinct depressed cicatrices, often pigmented in 
their circumference and fairly characteristic. The crops following 
one another, the different stages are observed simultaneously. The 
total duration is several months or several years, with a tendency 
to seasonal recurrences. 



TUBERCULOSIS 



567 



With this principal type, which may be designated as folliclis, 
the following varieties are connected. 

Acnitis of Barthelemy (Fig. 172) is seen in youthful or adult 
individuals, beginning and always predominating on the face, 
although sometimes scattered over the extensor surface of the 
limbs and the genital organs. The lesions consist of hard, miliary, 
distinctly circumscribed, isolated and indolent nodules, which 
originate in the depth of the cutis, may become absorbed, but more 
frequently suppurate and open on the surface, leaving a minute 
cicatrix behind. Each lesion lasts about one month, the eruption 
is continued over several months and is subject to recurrence. 




Fig. 172. — Acnitis in a man aged twenty years. 



Acne cachecticorum consists of slightly raised papulo-vesicular or 
superficial pustular miliary lesions, with a livid base, which appear 
in crops, without pruritus, in children or sometimes in adolescents 
or adults; they are situated principally on the limbs, to a small 
extent on the trunk and on the face and scalp. As a rule they 
are intermingled with lichen scrofulosorum or with typical papulo- 
necrotic tuberculides, of which they represent a superficial variety. 



568 INFECTIOUS BACILLARY DERMATOSES 

The name of ecthyma terebrans scrofidosorum may be applied to 
tuberculides related to the papulo-necrotic variety, but char- 
acterized by an eruption of lenticular or especially nummular, 
shallow and painless ulcerations which may coalesce in irregular 
patches; their course is slow, although occasionally acute. 

With the exception of the acnitis type, which usually seems to 
be pure, the other varieties have a tendency to become combined 
with each other. They also become associated with small deep 
nodosities, analogous to scrofulous gummas of very small size. 

Not to mention the coexistence of a local, glandular, etc., tuber- 
culosis, which is common, the combination of papulo-necrotic 
tuberculides with aero-asphyxia, with pernio, with lichen scrofulo- 
sorum, with lupus erythematodes, etc., is far from unusual. 

As their objective appearance is on the whole very polymorphous, 
when the various cases are taken into consideration, the differential 
diagnosis may have to be made from acne vulgaris, whose lesions, 
topography and course are entirely different; from some forms of 
folliculitis decalvans; and especially from papulo-crusted or follicular 
syphilides. Careful examination, however, will show that one is 
not dealing with the folliculoses, for the palmar and plantar regions 
may be involved ; lesions have been met with on the buccal mucosa. 
Hidrosadenitis must likewise be excluded. In other cases the 
differentiation is not easy from frost-bite, or lupus erythematodes 
with small patches, or still other tuberculides. 

The pathological anatomy will be discussed later. 

The treatment must aim in the first place at correcting the 
general hygiene and nutrition. So-called anti-scrofulous medica- 
tion with iodides, cod-liver oil and arsenic, is classical in these 
cases; calcium-salts remedies are indicated. I have obtained 
remarkable results from injections of calomel or soluble salts of 
mercury in cases with a negative YVassermann reaction. Still 
more serviceable are intravenous injections of arsenobenzol, com- 
bined with tuberculin injections in minimal and repeated doses. 
Locally, applications of ichthyol, methylene-blue, tincture of iodin 
or iodide powders, according as the lesions are ulcerated or not, 
seem to be useful. In obstinate cases, recourse may be had to 
cliinatotherapy, to heliotherapy and to cures at watering-places 
with saline, arsenic or sulphur springs. 

Lupus Erythematodes. — Although clinically and histologically 
very different from lupus vulgaris or Willan's lupus, erythematous 
or Cazenave's lupus is likewise destructive and disfiguring; hence 
its name. There is not so much difference in its true nature; if 
lupus erythematodes is an erythemato-atrophic tuberculide, as 
there is good reason to believe. 



TUBERCULOSIS 569 

Symptoms. — Lupus erythematodes consists of distinctly cir- 
cumscribed red patches, covered with adherent scales; they are 
only slightly infiltrated and have a tendency to become atrophied 
at their center; their course is slow; they occupy with predilection 
the face, the ears, the scalp, the back of the hands and the fingers. 

Each of these features deserves separate study. 

The redness is constant, sometimes of a light pink or again of 
a carmine or livid shade. It results from a persistent erythematous 
inflammation and fades under vitropressure. Very frequently, 
however, the congestion is accompanied by the existence of a fine, 
reticular or stellate network of telangiectatic capillaries and some- 
times by punctiform hemorrhages. 

The scaling is very characteristic but varies greatly in degree. 
In typical cases, a very adherent, more or less continuous, hyper- 
keratosis is demonstrable, formed by fine, greasy, dirty-white or 
chalky lamellae or stratified layers, which often look as if imbedded 
in a depression of the epidermis; rarely, the desquamation is psoriat- 
iform. When this hyperkeratosis is slightly marked, it consists 
simply of a whitish stippling around the follicular orifices. The 
thick lamellar or chalky layers present small horny processes on 
their deep aspect, which penetrate into the follicles and correspond- 
ing depressions of the epidermis. This punctate cornification is 
one of the characteristic symptoms of lupus erythematodes. 

The infiltration is very slightly marked and usually consists of 
a slight turgescence of the borders of the spot, the center being, 
on the contrary, depressed. Cardboard induration or discoid 
elevation of the patches is exceptional. 

On the other hand, cicatricial atrophy is invariable and char- 
acteristic, although very variable in degree and depth. Unna, on 
this account, gave lupus erythematodes the name of ulerythema 
centrifugum (dvkr) = cicatrix). The cicatricial atrophy (p. 339) 
results from absorption, without ulceration, of part of the cutis and 
of the infiltration. When mild and superficial, it manifests itself 
as a delicate white sclerotic network, with grayish punctiform 
meshes, or as a thin and flexible, not very noticeable patch; it is 
usually depressed, pearly white and slightly indurated; the deep 
forms of lupus erythematodes leave a white sclerotic spot, without 
hairs and glands, sometimes squamous or pigmented. 

The tenderness of lupus erythematodes spots on contact, pres- 
sure and especially scratching, is a sufficiently constant symptom 
to merit attention. 

The outlines of the spots are sharp, rounded, oval or polycyclic; 
they are always bordered by a narrow erythematous margin, even 
when the central redness is concealed by the hyperkeratosis. 

According to the relative importance of the dermic and the 



570 



INFECTIOUS BACILLARY DERMATOSES 



epidermic lesions, i 
appearances which 
employed 



ade between different clinical 
pecial names still sometimes 
herpes cretaceus of Devergie, 



distinction is n 

have received 
A case is described as 
when a massive surface hyperkeratosis is present; as acneiform 
lupus, when the hyperkeratosis is especially marked at the pilo- 
sebaceous orifices; as seborrhea congestiva (Hebra); or as erythemato- 
follicular lupus (E. Besnier), when there are oily crusts provided 
with very apparent conical processes, penetrating into the follic- 
ular orifices; as erythema eentrifugum of Biett, when congestion 

fine desquamation predominates. In lupus 



associated with 

exanthematicus the lesions are still less marked. 

It is noteworthy that in the majority of the cases the characters 
are not pronounced, or they are mixed so that their development is 
relied upon fully as much as their morphology for the description of 
the following varieties: 




Fig. 173.— F 



A. Lupus erythematodes discoides, or the fixed form, begins as 
one or several congestive, slightly infiltrated spots, promptly 
covered with adherent scales, spreading very slowly like a grease 
spot; their duration is counted by years. The hyperkeratosis and 
infiltration are usually very marked. The subsequent cicatrix is 
very atrophic; on the nose and ears it adheres to the cartilages 
which are themselves atrophic, hence rigidity, thinning and notable 
deformity of these parts. Recrudescence of the lesions in the 
cicatrix is not uncommon. This form is extremely obstinate. 

Discoid or fixed lupus erythematodes (Fig. 173) preferably 
occupies the cheeks, the ridge of the nose, the temples, the ears, 
the forehead, the scalp, the neck and more rarely the back of the 
hands. Not infrequently it is arranged as a continuous patch 
symmetrically covering the nose and both cheeks, known as butter- 



TUBERCULOSIS 571 

fly'or bat-wing lupus (vespertiUo). The spots, however, may also 
be irregularly scattered, sometimes there is only a single spot. 

Localization on the buccal mucosa is generally considered as 
rare, although Th. Smith (1906) found it in 16 out of 56 cases. 
Most commonly it occupies the posterior aspect of the lower lip, 
where the extension of a red festooned or frayed surface from a 
lupus patch beginning on the free border of the lip may be observed. 
Cases of lupus erythematodes of the mucous surface of the cheeks 
or palate are not very numerous; lesions have been observed even 
on the tongue, in the form of a red or purplish spot with a parch- 
ment-like center and radiating leukoplasic margins, resembling 
buccal lichen planus. The diagnosis can be confirmed only on the 
basis of a coincident lupus erythematodes of the face, or through 
biopsy. 

B. Lupus Erythematodes Migrans or Erythema Centrifugum of 
Biett. — Cases taking a relatively rapid course are connected by 
imperceptible transitions with stationary lupus erythematodes and 
their association is not uncommon. 

A tendency to symmetry, to bat-wing form, to involvement of 
the ears and the hands, is much more marked in lupus migrans. 
The mucous membranes were never found to be involved. 

The initial rose-colored spots grow in a few weeks, often present- 
ing raised borders due to a soft infiltration and a central depres- 
sion; they may become confluent in extensive surfaces. 

Desquamation is moderate and may be compared to that of 
pityriasis or psoriasis or seborrhea. 

The affection undergoes exacerbations, interrupted by long 
stationary stages. After healing, the cicatrix may be but slightly 
noticeable. The differential diagnosis from rosacea is sometimes 
difficult. 

C. Lupus Pernio. — There is no agreement as to the identity of 
lupus pernio, lupus frost-bites or chilblain lupus of Hutchinson 
and its relations with lupus vulgaris on the one hand and with 
lupus erythematodes on the other. Lupus pernio presents itself 
in the form of a bluish-red edematous swelling with diffuse borders, 
occupying the nose, the malar regions, the ears, the back of the 
hands and the fingers and more rarely the toes; it develops under 
the same conditions as frost-bite and is not infrequently com- 
bined with acro-asphyxia, with papulo-necrotic tuberculides, with 
angiokeratoma, etc. Sometimes there is considerable analogy 
with Raynaud's disease. The lesions may become atrophied or 
ulcerated, giving rise to disfiguring scars. The affection lasts 
many years, with prolonged remissions which occur especially in 
the warm season. 

When vitropressure or histological examination after biopsy 



572 INFECTIOUS BACILLARY DERMATOSES 

shows yellowish nodules analogous to lupus nodules in the spots or 
patches as is seen particularly on the nose, the condition would 
seem to be a true lupus pernio, representing a pathological type 
related to the sarcoids, for which the name of "benign lympho- 
granuloma" has been proposed (J. Schaumann). 

Swollen erythematous patches, with an atrophic central depres- 
sion, situated especially on the hands and fingers, may be said to 
be characteristic of chilblain lupus, which is probably related to 
lupus erythematodes. Both forms are entitled to classification 
under the heading of tuberculides. 

D. Lupus Erythematodes K.ranthematicus. — Under this name are 
described various rather rare erythematous tuberculides, character- 
ized by lilac-red, finely scaly centrifugal spots becoming super- 
ficially confluent. They may spread in two or three weeks from 
the face and hands to the neck, the trunk and the limbs. 

The acute form, described by Kaposi in 1S72, has been observed 
either in young women already suffering from stationary lupus ery- 
thematodes of the face; or primarily. The primary variety was 
investigated in 1908 by G. Pernet, who collected 10 cases, 9 of 
which occurred in women. The course is rapid, febrile, with 
arthralgias, albuminuria and severe general disturbances; it almost 
invariably leads to death in a few weeks or months, through toxemia 
or through lesions of the respiratory apparatus, the kidneys or 
the meninges. 

In the subacute form, the spots are disseminated and the general 
phenomena are absent, lengthy remissions occur and retrogression 
is possible. 

The dermatosis designated as erysipelas perstans faciei by Kaposi, 
or as erythema perstans by Jadassohn, in which the red and edema- 
tous patches appear in a given region, preferably in the center of 
the face, possibly belongs to the same type. 

Lupus erythematodes exanthematicus usually has no evident 
tendency toward atrophy. 

Diagnosis. — Lupus erythematodes is distinguished: from rosacea, 
by the limitation of the red spots and by their scaly atrophic 
character; from psoriasis and psoriatiform eezematides, by its 
punctate adherent hyperkeratosis and by its tendency to atrophy; 
from senile keratosis, by the age of the patients, by its more pro- 
nounced redness and its non-verrucous surface. 

The cicatrices of lupus erythematodes of the scalp differ from 
those of pseudofavus, favus and scleroderma in that they have 
followed upon a stage of severe reddening with hyperkeratosis. 
On the face or on the body, they must be distinguished from the 
idiopathic macular atrophies (p. 344) ; this is sometimes extremely 
difficult (Thibierge). 



TUBERCULOSIS 573 

I repeat that the differential diagnosis from papulo-necrotic tuber- 
culides, frost-bite and other tuberculides may be very puzzling, but 
is of minor importance. 

Lupus erythematoides (p. 554) is characterized by lupomas which 
are sometimes difficult to make out without the aid of biopsy. 

Etiology and Character. — Lupus erythematodes is observed very 
rarely in children before the eighteenth year or in aged individuals 
after sixty years; it is common from twenty-five to forty-five years, 
especially in the female sex and in cold climates. [In American 
dermatological practice it occurs once in about three hundred cases 
of skin diseases.] General circulatory disturbances, acro-asphyxia, 
a tendency to facial erythrosis and consequently the gastro-intestinal 
and utero-ovarian disturbances which are often primarily responsible 
for these conditions are thought to be predisposing factors. 

The most interesting question, however, concerns the relations 
of lupus erythematodes with tuberculosis. It results from an 
international inquiry conducted by the Annates de Dermatologie 
(April, 1907), that only a little less than one-half the authors 
accept its tuberculous origin, which has been conceded in France 
since 1881. It has not been demonstrated, but the opposite 
theories, which claim a toxinic, nervous or microbic pathogenesis, 
are still less firmly grounded. Lupus erythematodes is interpreted 
by Brocq as a cutaneous reaction, which may result from a variety 
of causes, the most common cause being tuberculous infection.. 
[This very nearly represents the opinion of Jadassohn also.] The 
following facts must be kept in mind: Many patients suffering 
from lupus erythematodes are tuberculous or very probably so; 
a few, however, seem actually free from tuberculosis. I have 
repeatedly seen patches of lupus erythematodes developing in 
connection with "scrofulous" lesions. The general tuberculin 
reaction is inconstant in these patients; the local reaction is absent 
in practically all of the cases. The histological lesions are inflam- 
matory and not tubercular [in the anatomical sense] ; giant cells are 
rare, no bacilli are found; these features are shared by several types 
of tuberculides. 

However, although it must be admitted that the number of 
cases is very small, Gougerot as well as Br. Bloch and Fuchs suc- 
ceeded in rendering guinea-pigs tuberculous through inoculation 
with tissue from lupus erythematodes. 

Summarizing, it may be stated that lupus erythematodes is 
certainly not a cutaneous tuberculosis like lupus vulgaris; never- 
theless, on account of its pathological relations, it may be grouped, 
although with some reservations, among the tuberculides. 

Treatment. — Without being positively grave, lupus erythematodes 
is disfiguring and very obstinate; it is rare for patients suffering 
from the disease to reach an advanced age. 



574 INFECTIOUS BACILLARY DERMATOSES 

The local treatment must be governed by the clinical form. 
One must avoid attacking with caustic agents superficial spots 
which max - disappear practically without a trace. In a general 
way, it is advisable to begin always by cautiously testing the 
patient's capacity of reaction, by means of astringent lotions, like 
lead water, or by applying weak ichthyol or resorcin pastes alter- 
nating with bland powders. 

Gradually more energetic methods are employed and these must 
be varied in the course of the treatment. Painting with iodin, 
carbolic acid, arsenic; pyrogallol, resorcin, salicylic acid, oil of cade 
or mercurial plasters, etc., are usually valuable. 

One of the best alterative agents is potash soap, which is applied 
during a time progressively lengthened from half an hour to eight 
or ten hours, to the point of producing an inflammatory reaction, 
which must then be controlled and the soap-treatment several times 
repeated. 

In the superficial and actively extensive forms, high-frequency 
currents sometimes yield remarkable and rapid results. 

In the stationary form, crossed linear scarifications or interstitial 
ignipuncture with the galvanocautery, more or less deep according 
to the case, constitute a classical treatment, the only objections 
to them being that they are rather painful and somewhat slow in 
action. 

Phototherapy is rarely successful; radiotherapy or radium are 
preferable, but difficult to apply, requiring extreme care in this 
particular instance. [I have seen excellent results follow the use of 
the Kromayer lamp applied with pressure.] 

On the whole, the therapy of lupus erythematodes is extremely 
disappointing. Patience and diplomacy are called for. It is 
important not to neglect hygienic measures and general treatment 
which is identical with that of an attenuated tuberculous infection. 
Long-continued administration of arsenic and especially of quinin 
in large doses, combined with iodin externally has been justly 
recommended. 

Pathological Anatomy of the Cutaneous Tuberculoses and Tuber- 
culides. This group of diseases comprises an entire series of lesions, 
from the most obvious bacillary tubercles to atypical and relatively 
common reactions. 

Tuberculosis. —There exists no tuberculous affection where better 
tubercles are found than in tuberculous ulcer (Fig. 101). It seems 
unnecessary to describe them here. They are arranged or scattered 
ncai' the floor and the borders of the loss of substance, but are often 
only slightly evident near the surface of the nicer itself. Koch's 
bacilli are abundantly present. Furthermore, there is a demon- 
strable inflammation of the connective and muscular tissues, as 



TUBERCULOSIS 575 

well as vascular lesions; their degree and their extent are variable, 
in different cases. 

The yellow granules of Trelat are due sometimes to intrapapillary 
or subpapillary agminated tubercles, undergoing a caseous degener- 
ation; in other cases to small superficial abscesses due to secondary 
infections. 

A tuberculous gumma in its formative stage consists of a mass 
of tubercles with typical nodules, in course of caseation. Bacilli 
are rarely present in considerable number. Sometimes the new- 
formation is encysted in a fibrous sheath, perhaps resulting from the 
dilatation of a lymph- vessel cavity; more frequently its boundaries 
are diffuse. In the stage of evacuation of the gumma, the tubercles 
are hidden in an abundant inflammatory tissue where they are not 
so readily demonstrable. 

In tuberculosis verrucosa, lupus scleroticus and anatomical 
tubercle, there are well-marked hyperkeratosis and hypergranulosis, 
hypertrophied interpapillary proliferations, elongated but very 
irregular and uneven papillae. The appearance at first sight is that 
of an ordinary papilloma, sometimes of a verrucous nevus. But the 
papillary body and the cutis are infiltrated with abundant round 
cells, sometimes collected in miliary abscesses. Moreover, scanty but 
very typical tubercles separated by sclerotic tissue may be seen here 
and there in the deeper portions of the cutis. Bacilli are present in 
variable number ; the result of guinea-pig inoculation is always p ositi ve . 

In fungoid tuberculosis, the tubercles and the bacilli are very 
thinly scattered in ordinary infiltration tissue. 

The pathological anatomy of lupus vulgaris is somewhat different 
in different cases. The most characteristic appearance has been 
described elsewhere in this book (Fig. 89). The collections of 
tubercles may be rich in giant cells or without these and composed 
solely of epithelioid cells ; sometimes the latter are absent and nothing 
is demonstrable but a diffuse infiltration of lymphoid and plasma 
cells, interspersed with enormous giant cells; the last-named struc- 
ture belongs especially to ulcerative and exuberant lupus. 

The lupus tissue in all cases is distinctly circumscribed; the con- 
nective tissue and elastic fibers stop at its circumference; this 
fact explains the softness, the translucidity and the very evident 
clinical boundary of lupomata. 

The lupus infiltration is situated at a very variable depth accord- 
ing to the clinical form; under the epidermis, in the corium, or as 
far as the hypoderm. In the last named layer or perhaps at a certain 
distance from the apparent nodule, it is not uncommon to meet with 
tuberculous infiltrations following the lymphatic or venous routes, 
or with aberrant islands, accounting for the very frequent recrudes- 
cences after a destruction supposed to be complete. 



576 INFECTIOUS BACILLARY DERMATOSES 

The connective tissue of the vicinity is often edematous and 
interspersed with lymphoid cells, sometimes frankly suppurating in 
cases of lupus with a rapid course. The question has arisen: is this 
inflammatory reaction due to a special virulence of the bacillus 
or to secondary infections? In other cases, there is a fibrous reaction 
with a tendency to encapsulation of the newformation, more par- 
ticularly in the forms capable of undergoing absorption. Lupus 
cicatrices often enclose latent nodules. 

The epidermis is sometimes passive, distended and atrophic, 
whereas in other cases it proliferates, vegetates and may grow so 
exuberantly that certain vegetating or papillomatous cases of lupus 
or framboesiform tuberculosis are suggestive of lupus-epithelioma. 
In proliferating lupus of an ulcerative appearance, the epidermis is 
often found to be reduced to its deep layers. 

Lupus is so poor in bacilli that their demonstration discourages 
the majority of histologists and very few have pursued it to the end. 
From forty to sixty slides often must be studied before a bacillus 
is encountered. The human bacillus is responsible for most of the 
cases. 

Inoculation into guinea-pigs, which react readily, necessitates 
the injection of at least 50 cgm. of lupus tissue, to be convincing; 
even under these conditions, it fails in one-third of the cases. The 
virulence of the bacillus is usually moderate and exceptionally 
attenuated. The tuberculin test, which is always positive requires 
doses of yo" of a milligram to 1.5 mgr. 

On the whole, lupus vulgaris is certainly a cutaneous tuberculosis, 
although in numerous respects it is related to the tuberculides. 

Tuberculides. — The histological lesions of the tuberculides are 
not uniform in character. Sometimes they have a tubercular 
structure, like the most positive bacillary tuberculosis, representing 
what I have named the tubercular type, or Type A; in other cases, 
they are of ordinary inflammatory character, representing my 
non-tubercular type B (also named atypical cutaneous tuberculosis 
by Pautrier, non-tubercular inflammatory tuberculosis, by Gougerot 
and numerous authors). I was led formerly to believe that the 
different tuberculides followed one or the other type of lesion, but 
have since recognized that the two aspects may coexist or succeed 
one another in the same clinical form. 

At any rate, it is usual to find typical tubercles in lichen scrofulo- 
sorum, where they are situated at the level of the papillary body; 
they are also met with in the hypodermic sarcoids and in erythema 
induratum. 

In the cutaneous sarcoids of Boeck, the infiltration as in some 
cases of lupus vulgaris and especially in lupus pernio, is composed 
for the most part of circumscribed collections of epithelioid cells. 



TUBERCULOSIS 577 

In the papulonecrotic tuberculides, the initial lesion is a small 
necrotic focus of the connective tissue which promptly becomes sur- 
rounded by a reactive inflammatory zone, whose lymphoid and 
embryonic cells are preferably arranged around the vessels. These 
more or less deeply situated foci, very superficial in acne cachecti- 
corum tend to rise and come to lie under the epidermis which is 
raised by a little serum, finally drying up in small crusts. In acnitis 
(Darier) and at the terminal stage of the papulonecrotic tuberculides 
(Brissy), very distinct tubercles may be encountered. 

The essential lesions of lupus erythematodes consist of the 
following: in the cutis, a diffuse and especially perivascular cellular 
infiltration, composed of small connective-tissue cells and lympho- 
cytes; plasmocytes and polynuclears are rare. Audry and Leredde 
found giant cells, which are of exceptional occurrence and usually 
associated with a disintegrated hair-follicle. Some bloodvessels 
are obliterated while others are dilated; small hemorrhagic points, 
lymphatic dilatations and often edema in the papillary body occur. 

The epidermis is in a state of partial horny atrophy, meaning 
that its Malpighian layer after at first having been thickened, is 
now atrophied and locally reduced to one or two rows of deformed 
cells; its stratum granulosum is missing at numerous points, the 
horny layer on the contrary is thickened, stratified and penetrates 
in cones into the sebaceous and sudoriparous pores and into the inter- 
papillary buds; the last named fact accounting for the clinical sign 
of "punctate keratosis." 

The disappearance of the elastic and connective-tissue fibers 
where the infiltration predominates, indicates the mechanism to 
which the final atrophy is due. The hairs fall out soon. The origin- 
ally enlarged glands finally disappear. 

Briefly, the condition is an endoperivasculitis with a tendency to 
atrophy and to hyperkeratotic atrophy of the epidermis. 

Koch's bacilli have been discovered in lichen scrofulosorum 
(Jacobi and Wolff) and in erythema induratum; with the aid of 
modern methods, with antiformin or by the Gram-Much procedure, 
positive results although open to controversy have, moreover, been 
obtained in nearly all the tuberculides, including lupus erythema- 
todes. 

In exceptional instances, guinea-pigs have been successfully 
rendered tuberculous through lichen scrofulosorum (Jacobi, Wolff, 
Pellizari, Haushalter, Lefebvre), through erythema induratum 
(Thibierge and Ravaut, C. Fox, Eyre, Carle), and through lupus 
erythematodes (Gougerot, Br. Block). Inoculation into monkeys 
is not more apt to be successful. 

The tuberculin test yields inconstant and often not very distinct 
results, although Jadassohn obtained a positive local and general 
37 



578 INFECTIOUS BACILLARY DERMATOSES 

reaction in 14 of 16 cases of lichen scrofulosorum ; it is also often 
obtained in erythema induratnm. I was equally successful in the 
three cases of subcutaneous sarcoids which were examined from this 
point of view. 

LEPROSY. 

Leprosy (lepra of the Arabs, elephantiasis of the Greeks, spedal- 
sked of the Norwegians, la lepre of the French, Aussatz of the Ger- 
mans) is a chronic infectious disease, which develops with periodic 
exacerbations and is caused by a special microbe, the Hansen 
bacillus. Numerous and varied cutaneous manifestations occupy 
a prominent place in the symptomatology of the disease. 

Leprosy seems to have existed from the earliest times among the 
peoples whose history has come down to us, notably in India, 
Egypt, Greece (alphos), China, etc. But it was confused with 
numerous contagious affections, so that the zaarath of the Bible 
has nothing in common with genuine leprosy (W. Dubreuilh and 
Bargues). In the middle ages, after the Crusades, it became widely 
distributed in Europe; numerous leper asylums were erected (over 
2000 in France) which in all probability erroneously harbored 
more than one case of tuberculosis or syphilis. 

[Originating in the Orient, leprosy was spread over Europe by 
the Roman armies and colonizers. There are ample records of its 
presence in France and England long before the Crusades but that 
great movement of men to and fro across Europe served to increase 
the number of cases enormously. In the fourteenth and fifteenth 
centuries the disease was common throughout the British Isles. 
Thereafter the epidemic gradually faded and the last autochthonous 
leper died in the Hebrides about a hundred years ago. The disease 
was carried to the West Indies, Mexico, Central and South America 
by the early Spanish settlers and by negro slaves from Africa. It 
reached the shores of the United States in the same way and more 
directly from the West Indies. In the Philippines with their large 
Spanish and Chinese population leprosy has been endemic for 
several centuries. In the Sandwich Islands it was introduced about 
the middle of the last century.] 

At the present day this disease is practically extinct in our 
regions. Autochthonous cases are rare in France, even in Brittany 
and Provence; Great Britain, Belgium, Switzerland, Germany, 
Austria, as well as the United States of America, are free from it or 
have only a few trifling local endemic foci. Lepers are more common 
in Norway, Italy, Spain and Algeria. In the Balkan Peninsula, 
in Southern Russia, in the Baltic Provinces and in Iceland, leprosy 
is fairly common. 

Among the most gravely infected countries, I shall mention 



LEPROSY 579 

Hindustan, Persia, China, Indo-China, Japan, Polynesia and not- 
ably New Caledonia and the Sandwich Islands ; Latin America 
[including some of the West Indies] may be considered as an 
important focus; certain parts of Africa are also more or less 
severely affected. 

[In the United States the largest focus at present is in Louisiana 
where it has existed since the first settlement. In the middle of the 
last century a considerable number of cases were imported into the 
Northwestern States by Scandinavian immigrants, but there has 
been no increase in these regions; on the Pacific Coast a small 
focus is due to importation from the Sandwich Islands and the 
Orient. There are a few sporadic cases in Texas, Florida and 
South Carolina. In the larger cities, cases are found among the 
emigrants from Russia, Italy, the West Indies, South America 
and China.] 

Owing to the facility and increasing frequency of communication, 
there are numerous opportunities for the importation of lepers into 
seaports and large cities all over the world. 

The authors to whom we are indebted for most of our knowledge 
on the subject of leprosy are: Danielssen and Boeck, Sr. (1846), 
Virchow, Hansen, Neisser, Besnier, Leloir, Lima, Zambaco, Ehlers, 
Jeanselme, etc. 

Etiology. — Leprosy is a disease of mankind and respects no race, 
no age, no social station, nor any climate or latitude. 

Leprosy is caused by the bacillus which was discovered by Hansen 
in 1871 and was more accurately studied and stained by Neisser. 
It resembles the Koch bacillus, but is shorter, more rigid, less 
regular in form and much more abundant in the lesions; it is acid- 
fast and stains by the Ziehl method as well as by the methods of 
Gram, Weigert and Much. 

It is not certain that real cultures of the Hansen bacillus have so 
far been obtained; of the positive results reported by numerous 
authors on more or less complicated culture-media, none have 
proved universally convincing. 

Inoculation of leprous tissue into all sorts of animals is usually a 
failure; but Ch. Nicolle, in 1905, apparently succeeded in infecting 
a Macacus sinicus, in which nodules made their appearance on the 
sixty-second day. 

The disease known as "rat leprosy," discovered by Stefansky 
in Odessa in 1903, which is distributed over the entire world, presents 
in certain respects, notably in the characteristics of its pathogenic 
agent, analogies with human leprosy, although it also differs from 
it very essentially. E. Marchoux, who recently investigated its 
modes of propagation in view of possible deductions applicable to 
human leprosy, found that it is transmitted especially through 



580 INFECTIOUS BACILLARY DERMATOSES 

bites or contact with an erosion, with flies as an accessory factor 
and perhaps sarcoptes and demodex, but not stinging insects. 

Human leprosy has long been considered as hereditary, although 
this interpretation still has its advocates, it is not proved by indis- 
putable facts; on the contrary, the children of lepers are known to 
remain free from the disease, provided they are removed at birth 
from the infectious focus. Few births occur among leprous families. 

The contagiousness of leprosy, on the contrary, is unquestionable, 
but its mechanism is not known and it seems to be subject to certain 
special conditions. Thus lepers who have been imported into 
countries free from the disease, for example Paris [or New York], 
where more than 150 lepers permanently reside, do not establish a 
local epidemic focus. Nevertheless Frenchmen often contract the 
disease in countries where leprosy prevails. This fact seems to 
support the theory of an intermediate host or parasitic carrier of 
the contagium, such as a mosquito which does not exist everywhere. 

Exceptional but demonstrative cases of transmission are, however, 
known to have occurred in our countries, like that of Hawtrey 
Benson's Irishman who was infected after his leprous brother's 
return from India, whose bed he had shared; or that of Veyrieres' 
patient who contracted the disease in Nice through her husband. 

In this connection may be mentioned the extremely rapid propa- 
gation of leprosy in the Hawaiian Islands and in New Caledonia, 
for instance, where a considerable portion of the population was 
infected in the course of ten or fifteen years. 

Poverty, dirt, promiscuity and prolonged contact are emphasized 
as favoring factors of contagion, which is supposed to occur indi- 
rectly, through the intermediation of clothing or ordinary objects. 
On the other hand, the presence of ulcerated tubercles, the dis- 
charge of secretions containing large numbers of bacilli, as is often 
true for the nasal mucus, the saliva and the genital secretions, 
serve to render the cases of "open leprosy" more dangerous. How- 
ever, the portal of entry in the contaminated person is unknown; 
the nasal fossse in particular, perhaps the digestive tube, the skin, 
especially the skin of the feet in bare-foot populations, have been 
considered as possible atria. 

Direct inoculation from man to man, accidental or experimental, 
is often ineffectual and demands great caution when made in 
countries where leprosy prevails. But the experiment performed by 
Arning, in the Hawaiian Islands, on the convict Keanu, in whom 
leprosy made its first appearance in the vicinity of the inoculated 
point, leaves little room for doubt. 

The incubation of leprosy has a duration certainly very variable 
and often very prolonged. 

Its medium duration fluctuates between three and five years; 



LEPROSY 581 

sometimes it seems reduced to a few months; often it is prolonged 
up to ten years and extreme cases have been quoted of fourteen 
years (Landouzy) and of thirty-two years ( ?) (Hallopeau) . It will 
be readily understood that the incubation period cannot always be 
accurately established. 

Symptomatology. — Period of Invasion. — The first manifestations 
frequently consist of general disturbances of a rather ordinary 
character. 

Depression, weakness, anemia and somnolence, are practically 
constant, as well as rheumatoid pains, arthralgias, backache and 
neuralgias; digestive disturbances are also noted (anorexia, dys- 
pepsia, coated tongue, transitory diarrheas) headache and vertigo. 

Fever is inconstant and often inconsiderable; but it may assume 
the form of intermittent attacks with temperatures of 104° and 105°, 
suggestive of malaria. 

Absence of sweating, or on the contrary attacks of perspiration, 
severe itching or tingling sensations and a persistent feeling of cold, 
have also been observed. 

Signs of a certain value are furnished by a dull coloration of the 
skin of the extremities, sometimes with local asphyxia or syncope; 
also by obstinate coryza or abnormal dryness of the nasal fossae 
with recurrent epistaxis occurring without an obvious cause. All 
these symptoms, the nature of which is often misunderstood, 
persist during months and years, extending into the subsequent 
periods. 

According to the tendency of the lesions to manifest themselves 
especially on the integument or on the nervous system, a distinction 
is made between tubercular leprosy [lepra tuberosum] and nervous 
leprosy [lepra nervorum}. 

Macular Period. — No matter what is to be the ultimate form of 
the disease, but especially in the tubercular form, an established 
leprosy generally manifests itself by spots or leprides, varying 
greatly in color, dimensions, abundance and duration, developing 
in irregular crops. 

They occupy the face, the extremities, the extensor side of the 
limbs, especially the buttocks and the back. They may assume the 
appearance of a polymorphous, papular or nodular erythema, with 
general symptoms, taking a sluggish course. Most commonly they 
appear in the form of erythemato-pigmentary spots, of variable 
size (Fig. 174), sometimes simply congestive, or purely achromic 
or hyperchromic. Although not infrequently pruritic or painful 
at the onset, they are nearly always characterized by their hypo- 
esthesia or their anesthesia, which is usually of the thermo-analgesic 
type. They are diffuse or circumscribed and frequently arranged in 
circles, rings or serpiginous lines. After the first appearance they 



582 



INFECTIOUS BACILLARY DERMA TOSES 



are often ephemeral and may vanish without leaving a trace; later 
on they become persistent. 

The erythematous spots may cover large areas, simulating ery- 
sipelas or polymorphous erythema; as a rule, they soon become 
more or less purplish or bronzed or copper-colored, or less colored 
than the background in the colored races, and are covered with fine 
scales; transitory at first, they persist after a recrudescence, spread- 
ing like a drop of oil and becoming decolorized at the center. The 
tubercles usually develop upon these spots. 




Fig. 174. 



-Ervthemato-pigmented leprides, in a boy aged cloven years, son of 
a French official in Cayenne. 



The pure pigmentary or achromic spots, belonging more par- 
ticularly to the nervous form, present all the above-mentioned shapes 
and an entire color-scale, from black at one end to pure white at 
the other. They are often leuko-melanodermic, the center being 
depigmented and the circumference hyperchromic (morphea leprosa). 
They may simulate vitiligo (vitiligo gravior), chloasma, pigmentary 
syphilides, pityriasis versicolor, etc., hut are characterized by their 
anesthesia. In colored individuals, leprous achromia produces a 
variety of "piebald negroes." 

The combination with erythematous spots is fairly common and 
<jives rise to peculiar checkered designs. 



LEPROSY 583 

Following the macular period, or in place of it, pemphigus leprosus 
may occur, being much more commonly observed in the nervous 
form. It consists of voluminous but not very numerous bulla?, 
preferably affecting the back of the hands and feet, the elbows and 
the knees and often the surface of the achromic spots. Evacuation 
of their clear contents leaves a red or inflamed excoriation which on 
healing leaves a nacreous anesthetic cicatrix, with pigmented borders, 
possessing great diagnostic value. 

The crops of bullae recur in the course of the trophoneurotic stage. 

Tubercular leprosy [lepra tuberosum] the tubercular or nodular form 
of leprosy — or lepre systematise tegumentaire of Leloir — is charac- 
terized by leprous, tubercles or lepromata. 

A tubercle which remained solitary for several months, has in 
rare instances been the first manifestation of the disease, as observed 
by Leloir, Marcano and Wurtz, and Gougerot; by analogy, this has 
been described as leprous chancre. 

The tubercles are sometimes derived from the slow and partial 
transformation of erythemato-pigmented leprides; in other cases 
they develop in crops with abundant lesions, sometimes with febrile 
or afebrile general disturbances. 

Their vaguely symmetrical localization is approximately that of 
the spots, with a predilection for the face and ears and possible 
extension to the mucous membranes. 

Hypodermic lepromata are also observed, perceptible to the 
touch as circumscribed nodosities or infiltrated and nodular patches 
(Chapter XIV). 

The leprous tubercles (Fig. 175) and the cutaneous leprous infil- 
trations have been described elsewhere in this book (p. 258), and 
I have pointed out their possible termination in leprous morphea 
and in leprous ulcers. 

There still remains to be traced the picture of the topographical 
distribution of lepromata. Not infrequently they lend a character- 
istic appearance to the invaded regions. In the face, this aspect 
is described as fades leonina or leontiasis leprosa; the forehead is 
puckered, traversed by deep wrinkles; the region of the eyebrows 
is thickened and hairless; the nose is deformed, thickened and 
enlarged; the cheeks, the lips and the chin are lobulated and the 
beard is reduced to a few thinly scattered hairs. All these surfaces 
are of a red, brownish or grayish color. In very pronounced cases, 
the disfigurement is such that the race, age and sex of the patient are 
no longer recognizable. 

The ears of lepers are typical, with an enlarged auricle studded 
with tubercles or seamed with cicatrices, a thick, hanging and 
flabby lobule in which numerous "birdshot" granules are demon- 
strable on palpation. 



:>vi 



INFECTIOUS BACILLARY DERMA TOSKS 



The scalp almost invariably escapes and the luxuriant hair on the 
head of lepers contrasts with their hairless face and the loss of the 
body-hairs. 

On the extremities, the elbows, the knees and the prominent 
portions, including the fingers and toes, are deformed by brownish 
or purplish tubercles. The integumenl as a whole has a dusky, 
tawny, earthy, in places cyanotic color, a flabby, withered consist- 
ence and a peculiar dryness. The nails are dry, brittle and may fall 
out. In the lower limbs, a pachydermatous condition justifying the 
name of elephantiasis of the Greeks is not uncommon. 



i^b 



Fi<;. 175. — Leprous tubercles of the lace. Note the alopecia of the eye-brows and 
interstitial keratitis, with iritis of the left eye. 

Lymph glands are usually enlarged early and may attain an 
enormous size, without, however, undergoing suppuration. 

Localization on the mucous membranes and on the special sense 
organs is very common. 

In the nasal fossae, the obstinate bacilliferous coryza and epistaxis 
of the onset urc followed by lepromata or ulcers of the septum, 
leading to perforation as in syphilis, with breaking down of the nose. 

The mouth may be the seat of lepromata or cicatrices affecting 



LEPROSY 585 

the palate, the velum, the uvula, the pharynx and the back of the 
tongue. 

The larynx is often attacked at an early date, hence hoarseness 
of the voice, aphonia, dyspnea after exertion and later on attacks of 
suffocation. 

The eye is affected with deplorable frequency, especially in its 
anterior hemisphere. Leprosy here very rapidly gives rise to tuber- 
cles on the conjunctiva, interstitial keratitis with superficial pannus, 
episcleritis, iritis; the bacillary infiltration of the iris is sometimes 
manifested by nodules, almost invariably by exudates which impair 
vision. The ciliary body is more frequently invaded than the choroid 
and the retina. Attacks of glaucoma, secondary cataract and 
atrophy of the eye-ball, may hasten the loss of the eye. 

Visceral leprosy is here only mentioned by name; it affects the 
lungs, where the differential diagnosis from tuberculosis which some- 
times complicates it, is not easy but possible by bacteriological 
methods; the digestive tract, the liver, the spleen, the circulatory 
apparatus, etc., may also be affected. 

Leprosy of the genital apparatus is common, especially in man. 
Orchitis leprosa is observed in at least one-third or one-fourth of the 
cases; it may be acute at the onset; as a rule it is an insidious 
bilateral orchiepididymitis, of which the patient is not aware; the 
organ is smooth or nodular, but hard and undergoes atrophy. The 
lesions lead to early sterility, without loss of libido and later to 
impotence. Not many data are available on leprosy of the female 
genital apparatus; its different parts, notably the ovaries, may be 
damaged and undergo sclerotic atrophic changes; according to 
Babes, about 70 per cent, of female lepers are sterile. 

The course of tubercular leprosy is very variable; it is rarely acute 
and fatal in a few months, but usually chronic, lasting ten or twenty 
years and longer. The attacks are interrupted by prolonged remis- 
sions, with retrogression of all symptoms, simulating a cure. These 
remissions are the rule in our countries. When the course is pro- 
gressive, the ulcerations, the suppuration, the fever and diarrhea 
lead to marasmus and death, which often occurs as the result of 
severe local disturbance or a superadded complication. 

Lepra Nervorum. — The second ordinary type of established leprosy 
is the generalized nervous form or lepra maculo-anesthetica or tropho- 
neurotica. 

It likewise begins almost invariably with macules; it is not certain 
that these may be entirely absent. Frequently they are large and 
perfectly symmetrical; disturbances of pigmentation are marked. 
The macular stage is sometimes indefinitely prolonged, so that a 
form of so-called macular leprosy [lepra maculosa] has been described. 

In other cases, the onset of the disease is marked by pemphigus 



586 INFECTIOUS BACILLArV DERMATOSES 

leprosus which occurs in attacks sometimes leading to sloughs and 
frightful mutilations; sonic authors have accordingly recognized a 
macular and bullous form of the disease, known as Lazarine leprosy. 

As a rule, nerve leprosy is characterized by tumefaction of certain 
nerves, by anesthesia and by trophic disturbances of the skin, the 
muscles and the bony framework. 

The nerves accessible to palpation, notably the ulnar nerve above 
the bend of the elbow, the external popliteal, or the superficial nerves 
of the cervical plexus or the forearm, are cylindrically thickened or 
more often the seat of spindle-shaped swellings or beaded nodosities. 

Although painful at first, they soon become insensitive and at the 
same time cutaneous anesthesia is developed. 

Neuritis manifests itself by neuralgic pains, sometimes intoler- 
able, circumscribed areas of pain, pruritus unrelieved by scratching, 
sensations of numbness, "dead fingers," local cyanosis, sudoral 
disturbances, etc. 

The anesthesia, which possesses great diagnostic value, was care- 
fully studied by Jeanselme. It particularly affects the extremities 
symmetrically, first the lower limbs, progressing from the periphery 
to the center. Band-like at the onset, occupying for instance on 
the upper extremities the little ringer and the ulnar border as far as 
the axilla, at the lower limb the big toe and the internal border of 
the foot and leg, it subsequently assumes a segmentary type. It is 
variably distributed; outside of the territory where it is established, 
there exists a movable anesthetic zone, imperfectly bounded by a 
transitional area; at its origin it is superficial, but shows a tendency 
to increase in depth. The anesthesia is dissociated; the tempera- 
ture sense is lost first, next, sensibility to pain disappears and much 
later the tactile and pressure sensations. Sensory perversions and 
retarded sensation are not uncommon. Finally the loss of sensation 
becomes total, at least at the extremities; deep burns may occur, 
the patient remaining unconscious of them. 

Muscular atrophy affects especially the face and the extremities. 
In the face, the orbicularis palpebrarum is first attacked, as a rule, 
causing inability to close the eyes and its sequel*. 

The forehead, the cheeks, the circumference of the mouth are 
attacked in their turn. The emaciation of the face, the pale and wan 
complexion, the fixity of the features with lagophthalmos, lend the 
face a strange appearance, known as "fades Antonina." 

On the hands, the muscular atrophy affecting the thenar and 
hypothenar eminences as well as the interossei, leads to deformity in 
the Inn 11 of ulnar Hair, or of boat-shaped hollows on the back of the 
hand, or to one of the types of chronic rheumatism. It later involves 
the forearm and especially the extensors and sometimes the upper 
arm. There is no paralysis but only a diminution in strength pro- 



LEPROSY 587 

portionate to the atrophy. On the feet, the plantar muscles are the 
first to be attacked, but the atrophy of the anterior tibial and the 
extensors of the toes attract more attention, causing a varus equinus 
position and a halting gait. 

The bony and articular lesions which are characteristic of lepra 
mutilans are derived either from penetrating ulcers, or from malum 
perforans, which is frequent and is distinguished by its depth and 
total anesthesia, or from panaritium terminating in necrosis, as in 
Morvan's syndrome; or from dry gangrenes; and often also from 
bone absorption without external lesion. The foot and the hand 
may be reduced to irregular stumps which have been compared to 
elephants' feet (elephantiasis of the Greeks) or to the paws of seals. 

Nerve leprosy takes a slower course and has an even longer 
duration than tubercular leprosy; it is not uncommon for it to exceed 
twenty years. In the advanced stages, the condition of the patients 
is extremely distressing; they are emaciated, mutilated, blinded, 
paralyzed, suffer from intolerable neuralgias, persistent cold, 
unquenchable thirst, often from infected ulcers and are sunk in 
deep apathy, melancholia and marasmus. A toxemic psychosis of 
lepers has recently been described. Death supervenes through 
cachexia, purulent infection, pneumonia, diarrhea, nephritis, and 
occasionally through tuberculosis. 

Mixed Form. — It must be understood that the two preceding 
pictures of tubercular leprosy and nerve leprosy are more schematic 
and didactic than in conformity with the ordinary appearances. 

Almost invariably, while one of these groups of symptoms pre- 
dominates, there occur the most varied associations and com- 
binations. Mixed or complete leprosy is by far the most common, 
either from the start or more frequently as a result of modifications 
in the course of evolution; the tubercular form especially tending 
to become gradually complicated by nervous and trophic disturb- 
ances. 

Pathological Anatomy. — Leprous tubercles or lepromata are made up 
of a sharply limited and very coherent intradermic infiltration, under 
a normal although stretched epidermis; it is separated from the 
basal layer by a thin band of normal tissue with a wavy lower border 
and is prolonged in cuff-form around the vessels, which are affected 
with endoperi vasculitis and around the nerves, the lesions of which 
are inconstant, as well as around the glands. 

The infiltration is made up principally of the "lepra cells" of 
Virchow, large cells with a clear and vacuolated protoplasm, some- 
times polynuclear; furthermore, by connective-tissue cells, a few 
lymphocytes, mast-cells and occasional plasmocytes; sometimes 
giant cells are found. Bacilli are more abundant than in any other 
microbic disease; they are arranged in clusters or bundles, especially 



588 INFECTIOUS BACILLARY DERMATOSES 

in the lepra- and connective-tissue cells and are sometimes extra- 
cellular and agglomerated in a glairy substance (glcea); the name 
of globi is applied to balls or strands composed entirely of bacilli. 
Caseation is not found in lepromas. 

In recent spots or leprides, only perivascular cuffs of round cells 
are found, which in the course of the successive exacerbations 
become mixed with lepra-cells at first not very large. The pro- 
gressive increase and confluence of the perivascular infiltrations 
lead to the transformation of the spots into tubercles. In opposition 
to prevailing opinions, I showed in 1897 that there are merely differ- 
ences in degree between these two lesions and that leprides regularly 
contain, from their onset, a number of bacilli which although not 
very considerable can nevertheless be demonstrated by a suitable 
technic. [In 1899, in Unna's clinic, I was able to demonstrate a few 
bacilli in the apparently normal skin of a leper after a febrile attack.] 

The cutaneous manifestations of leprosy result from bacillary 
embolisms. Several authors have noted a bacillemia at the time 
of the exacerbations, accompanied by polynucleosis; after the 
crisis a transitory lymphocytosis follows and then a persistent 
eosinophilia, which is sometimes very marked (over 30 per cent, 
according to Gaucher and Renaut). 

Leprous neuritis was described by Virchow. When the nerves 
are involved, they present the changes of parenchymatous and 
sclerotic neuritis, of peripheral origin and centripetal course, 
according to Gerlach, Dehio, etc., or with multiple points of attack. 
Abundant collections of bacilli may be found, especially in the 
mixed form. 

Diagnosis. — The disturbances of the period of invasion are gener- 
ally not referred to their true cause until after the appearance of 
more significant manifestations. 

The question of a possible leprosy most frequently arises in con- 
nection with erythematous or pigmented spots or even of tubercles, 
which may be solitary or agminated in lupoid or syphiloid patches; 
in other cases, attention is aroused by nervous disturbances sug- 
gestive of polyneuritis, tabes, rheumatism, or especially syringo- 
myelia, progressive muscular atrophy, scleroderma, Raynaud's 
disease, etc. The features of these disturbances, for instance 
anesthesia or thermo-analgesia of the spots or tubercles, may 
sometimes suggest the diagnosis of leprosy from the start. This 
supposition will be strengthened by knowledge of the patient's 
nativity or his sojourn in contaminated countries. The important 
point is to keep leprosy in mind. 

The impression received should always be controlled by thorough 
inquiry and by laboratory tests. 

In the first place, the so-called permanent stigmata of leprosy 
must be looked for; a dusky, cyanotic and pigmented coloration 



LEPROSY 589 

of the face and the extremities, with softness and dryness of the 
skin; alopecia of the beard and body, especially alopecia of the 
external half of the eyebrows; tubercles of the ear-lobule; tume- 
faction of the nerves, notably the ulnar nerve; atrophy of the 
muscles of the hand; anesthesias; scars from bullae on the elbows 
and knees; leprous orchitis; ocular manifestations such as paresis 
of the orbicularis, conjunctivitis and episcleritis; rhinitis with 
hypersecretion and epistaxis, or even perforation of the septum; 
hoarseness of the voice, etc. 

Absolute scientific proof is furnished by the demonstration of the 
bacilli. These may be found: by biopsy of a leproma or a lepride, 
in sections or on a smear preparation of a piece of excised tissue; 
in default of these procedures, in an extirpated gland, with or with- 
out the aid of the antiformin method; in the nasal mucus, especi- 
ally in the tubercular forms after the administration of 4 grams of 
iodide two days in succession if necessary. 

The intradermo-reaction to leproline, which was tried by Mantoux 
and Pautrier; also, the sero-agglutination proposed by Gaucher and 
Abrami; as well as the complement-fixation reaction, with a leproma 
extract as the antigen; all these are undoubtedly valuable methods, 
but cannot as yet be described as entirely satisfactory. It must be 
remembered that the blood serum of lepers, even those free from 
syphilis, usually yields a positive Wassermann reaction and that 
eosinophilia is common in their blood. 

Prognosis and Treatment. — As to the curability of leprosy, it must 
be remembered that prolonged remissions and arrest of the disease 
which might be considered as cures, have been observed even in 
countries where leprosy is endemic. 

Moreover, there are incomplete (fruste), benign forms in which 
the symptoms are reduced to a few spots, circumscribed anesthesias, 
partial amyotrophies, without any further evolution. A recru- 
descence, however, is always possible. I have repeatedly observed 
the redevelopment of a checked leprosy at the time of the patient's 
return to the land of origin of the disease. In short, the possibility 
of a cure of leprosy must be conceded, but with reservations. 

The prophylaxis is more important than therapeutic measures. 
The rule of compulsory reporting of cases and relative isolation of 
the patients, although harsh in its application, has yielded such 
brilliant results in Norway (243 cases in 1902, where there were 
2598 in 1856) that it should be enforced in all contaminated coun- 
tries with modifications to suit conditions. Occupations which 
involve the risk of the spreading of the contagion must be forbidden 
to lepers. 

Persons who come in contact with lepers must practise measures 
of scrupulous cleanliness and strict personal hygiene. The lepers 
must be regularly bathed, cleaned and bandaged. As far as possible, 



590 INFECTIOUS BACILLARY DERMATOSES 

they must be advised to leave the infected countries and to reside 
in a healthful temperate climate; under these conditions, lasting 
improvements and quasi-cures are sometimes observed. 

No medication possesses an absolutely specific value. Mercury 
in soluble injections, or in the form of calomel or gray oil, seemed 
to give good results in my experience and in that of ('rocker, Ehlers 
and Ilaslund. Iehthyol, salol and salicylates have been recom- 
mended. Treatment with arsenobenzol is useless. The classical 
treatment, the best on the whole, although its value is disputed, 
is chaulmoogra oil, given in doses of V drops, progressively increasing 
to CL and CC, in emulsion or better in capsules, for periods of two 
months, several times during the year. Given by the mouth, it is 
often not well tolerated; I have always been pleased with intra- 
muscular oily injections according to the formula of Brocq (chaul- 
moogra oil, 70 cm., eucalyptol 30 cm., in sterilized ampoules of 5 
cm.). Its substitutes, gynocardic acid and gurjun balsam, seem to 
be less active. Opinions differ concerning the value of nastine 
injections; the name nastine is applied to products derived from 
cultures of a streptothrix extracted from lepromata by Deycke; 
these injections have sometimes proved injurious. 

[There is no doubt that cases of leprosy have been arrested and 
possibly cured by chaulmoogra oil. The problem is to introduce 
the remedy in sufficient dosage. Hollmann and Dean (Honolulu) 
have recently published some very striking results obtained by 
subcutaneous injections of ethyl esters of chaulmoogra fatty acids.] 

Very hot baths bring great relief and a sense of well-being to 
lepers, especially in painful cases. 

The tubercles break down and disappear on cauterization with 
the galvanocautery. The ulcers must be kept very clean and covered 
with moist aseptic dressings; I have obtained good results from 
daily painting with Mencieres fluid [therapeutic notes, section 3]. 
The ocular lesions are benefited by subconjunctival mercurial injec- 
tions, atropin and warm local douches. 

In a general way, different local measures are required, according 
to the nature of the lesions and their seat. There is no doubt but 
that an actively and persistently treated case of leprosy takes an 
infinitely more favorable course than when the disease is left to itself. 

The future undoubtedly belongs to a serum [or chemotherapeutic] 
treatment which still remains to be discovered. 

GLANDERS. 

Glanders (French, la morve, German, Rotz) [Malleus] is a very 
grave contagious and inoculable microbic disease which affects 
Soliped animals and is transmissible to man. It takes an acute or a 



GLANDERS 591 

chronic course. In different cases, the general symptoms, or the 
visceral lesions or the cutaneous and mucous lesions predominate. 

There is no valid reason for maintaining the formerly made dis- 
tinction between glanders on the one hand, an internal disease 
affecting the respiratory apparatus and especially its first passages, 
the nasal fossae — and farcy on the other, an external disease affecting 
the skin and hypoderm; for their cause is identical. 

The frequency of glanders in horses and asses had considerably 
diminished in France before the war, especially since the discovery 
of malleine, a secretory product of the bacillus, made its early 
diagnosis possible. 

Human glanders, which is rare, is in the vast majority of the cases 
of direct equine origin, so that those whose occupation puts them 
in contact with horses are apt to contract it by cutaneous inocu- 
lation, without there necessarily existing a demonstrable erosion. 
It seems probable that infection may also occur through the nasal 



The bacillus of glanders is slender and shows clear spaces [vacuoles?] 
it does not take the Gram-stain; it can be stained by Weigert's 
method or by Nicolle's method with tannin, but easily becomes 
decolorized. Its cultures on potato assume a tawny, then brownish 
color and are characteristic. It is very dangerous to handle and can 
be successfully inoculated into all laboratory animals. 

Glanders pus introduced under the guinea-pig's skin gives rise 
in a few days to a swelling from which culture-material may be 
extracted; on injection into the peritoneum of a male guinea-pig, it 
gives rise in three days to a severe orchitis. Straus pointed out the 
value of the last-mentioned reaction for the diagnosis, but it is 
not absolutely conclusive. The serum of animals having glanders 
agglutinates the glanders bacillus at 1 to 500 or 1 to 1000; but 
agglutinins may also exist in some normal sera. The comple- 
ment-fixation test is made by means of an extract of bacilli as 
antigen. 

The anatomical lesions of glanders are characteristic only when 
they are found to consist of glanders granulations; the latter have 
been compared to tubercles, but are rather minute abscesses, com- 
posed principally of polynuclears; they become necrotic and liquefied 
in their center; a peculiar fragmentation of the nuclei occurs, 
known as chromatorhexis. 

The clinical forms are multiple and very dissimilar : 

Acute glanders is a blood-infection, a septico-pyemia, which 
occurs primarily or as the result of cutaneous inoculations (farcy 
chancre) and sometimes as the termination of the chronic form. 
It assumes a typhoid or rheumatoid course, or especially that of 
pyemia, with a remittent, later an irregular fever, great weakness, 



592 INFECTIOUS BACILLARY DERMATOSES 

arthritis, respiratory symptoms, a grave general condition; it kills 
in five to twenty days. 

Its cutaneous manifestations may consist at the onset in an 
ascending lymphangitis of the limbs promptly followed by abscesses; 
or in erysipeloid swelling of the face, of dark red color, with diffuse 
borders, without elevation, on which blisters or sloughs make their 
appearance; ultimately, after several days, a disseminated pustular 
eruption develops, resembling variola but not umbilicated and with 
a tendency to ulceration and gangrene; sometimes, abscesses appear 
and as they multiply cover the limbs with so-called "farcy-buds," 
(acute farcy). 

Chronic glanders behaves like a localized infection with a tendency 
to become generalized in exacerbations. It manifests itself as 
phagedenic penetrating ulcers and abscesses; these are situated on 
the face or on the limbs. The clinical picture becomes complicated 
by general, febrile, articular, testicular, digestive and respiratory 
disturbances and usually terminates in acute glanders; a cure is rare; 
as a rule it is merely apparent or temporary. The duration is from 
eight to fifteen months or sometimes several years. 

Mutilating glanders of the face is the most interesting form for the 
dermatologist. It begins with tuberculo-ulcerative lesions of the 
nasal fossae or the buccal mucosa; by extension and by accessory 
dermic abscesses originating in the vicinity, the ulceration (which 
has a puckered floor, livid margins and a profuse discharge of yel- 
lowish pus) reaches the face, destroys the soft portions of the nose, 
the cheeks, the lips and sometimes the nasal septum, exposing the 
bones without attacking them; the glands are usually enlarged. 
Festooned borders, as if gnawed by the teeth of mice, and pustules 
or aberrant sloughing ulcers are features which should attract 
attention. Observations concerning this form of glanders are rare 
(Hallopeau and Jeanselme, Besnier, E. Hoffmann); probably some 
cases are not recognized. The differential diagnosis is difficult from 
tertiary or hereditary ulcerative syphilide; lupus vorax; mycoses; 
[espundia] and other phagedenic affections. Laboratory tests are 
required for its confirmation. 

Treatment. — There is no specific treatment for glanders at the 
present time. Treatment with mercury, iodides and arsenobenzol, 
which have been empirically tried, is without reliable effect. Hence, 
in cases with a known initial lesion or in chronic ulcers due to glan- 
ders, the question of excision arises when this is practicable, or of 
cauterization with the actual cautery. Radiotherapy might serve 
to dry out the ulcers and inhibit their progress. The abscesses must 
be immediately incised, scraped and disinfected. But the prognosis 
is extremely gloomy. 



ANTHRAX— MALIGNANT PUSTULE 593 

VERRUGA PERUANA. 

Verruga — also named Carrion's disease or Oroya fever — is a 
severe infectious, frequently fatal, disease, which is endemic in 
some Peruvian valleys. 

It begins with septicemic symptoms, an irregular fever with 
rheumatoid pains; followed at the end of a few weeks or months by 
an eruption of numerous scarlet red pruritic miliary elevations, which 
increase in size and become pedunculated. There are also larger 
warty or fungoid nodosities which appear in variable number. 
Whether small or large, the lesions are extremely vascular and bleed 
readily; they have at first the structure of a granuloma, which 
becomes areolar through marked dilatation of the blood and lymph 
vessels. The eruption predominates on the face, the neck and the 
extensor surface of the limbs ; the mucous and serous membranes as 
well as the viscera may be invaded. 

The pathogenic agent reported by Izquierdo (1885) was redis- 
covered by Letulle and by M. Nicolle; it is an acid-fast bacillus. 
Others have looked for it in vain and suspect a special paratyphoid 
bacillus or a protozoon. Many quadrupeds are susceptible to the 
disease. Infection is supposed to occur through water or through 
stinging insects. Verruga confers immunity. 

No specific treatment for the disease is known. 

ANTHRAX— MALIGNANT PUSTULE. 

Malignant pustule is the manifestation of a local inoculation with 
the bacillus anthracis discovered by Davaine. 

In man, this inoculation almost invariably results from occupa- 
tional handling of diseased animals, sheep, goats, horses, cattle, etc., 
or especially of their hides, where the very resistant anthrax spores 
persist indefinitely. Malignant pustule therefore usually occupies the 
exposed parts and is observed in shepherds, veterinaries, butchers, 
tanners, leather-dressers, brush-makers, wool-sorters, workers in 
horn, etc. [Several cases of infection from shaving-brushes have 
been reported.] Infection through contaminated flies, often held 
responsible by the laity, is possible but exceptional. 

Comparable at the onset to a flea-bite, on which a vesicle promptly 
arises, the pustule becomes indurated and presents a brownish or 
purplish, granular lenticular spot, which spreads and becomes a 
slough encircled by vesicles. Itching is rather severe. The circum- 
ference of the lesion is the seat of a dark red inflammatory edema, 
sometimes with strands of lymphangitis. The entire region is 
invaded by a gelatinous infiltration. Finally, the slough is shed, 
the gangrene increases in depth and in extent, the phenomena of 
general infection appear; they consist of a high fever, with a weak 
38 



594 INFECTIOUS BACILLARY DERMATOSES 

irregular pulse, difficult respiration, sweats, hemorrhages and 
delirium; death occurs in collapse. 

The duration of this course varies from twenty-four hours in 
fulminating cases to twelve or fifteen days. A spontaneous cure is 
possible, hut must not be expected. 

The name of malignant edema has been employed for a variety in 
which the central slough is absent; the symptoms consist of a soft 
swelling with vesicles and of early signs of severe septicemia. 
Anthrax edema is seen especially on the eyelids or on the lips. 

Treatment. — The old treatment, by excision or cauterization with 
the actual cautery, is at all promising only on a very recent and still 
doubtful lesion. Repeated injections, around the pustule, of a 
carbolized or iodine-iodide solution have been recommended; 
arsenobenzol has been successfully employed. These measures, 
however, must make way for serotherapy. Anti-anthracic serum, 
introduced by Marchoux in 1895, since investigated by Sclavo and 
others, must be employed in subcutaneous injections of about 40 c.c. 
and repeated several days until the edema diminishes; it will cure 
malignant pustule provided it is employed at the onset and even 
sometimes when the blood-culture is already positive. 

CUTANEOUS DIPHTHERIA. 

Although reported by Chomel and Samuel Bard in the eighteenth 
century and described by Trousseau, cutaneous diphtheria has 
become definitely characterized only since the discovery of the 
Klebs-Loeffler bacillus. It is discussed in numerous publications, 
of unequal value, the most important being the contributions of 
Neisser, Schucht, as well as the reviews- of Marchalko, Knowles and 
Frescoln (1914). It must be distinguished from the ordinary erup- 
tions of urticaria, erythema and purpura, which are frequently 
observed in diphtheritic patients, especially in those who have 
received serum injections. 

Cutaneous diphtheria, due to the growth of the diphtheria 
bacillus on the skin, is as a rule secondary to involvement of the 
mucous membranes and the result of auto-inoculation. More 
interesting, but less common are the cases in which it is primary and 
exclusively localized on the external integument; these are derived 
from direct contagion by a diphtheritic patient or a germ-carrier, or 
from indirect contagion by clothing, bedding, dressings, etc. It 
must be kept in mind that although diphtheria principally attacks 
youthful individuals, no period of life escapes the disease. 

Symptoms. — I ndoubtedly the most common clinical form is that 
beginning with spots or patches of eczematiform dermatitis, situ- 
ated at the circumference of the orifices of the mucous cavities in 
which the diphtheria runs its course, for example under the nostrils, 



CUTANEOUS DIPHTHERIA 595 

around the mouth, the eyes or ears, and also around the vulva, the 
prepuce and the anus, Wounds or even the slightest excoriations, 
located anywhere, impetigo, herpes, cracks, intertrigo and more 
particularly surfaces which have been denuded by blisters (the 
danger of which in diphtheria was emphasized by Trousseau), are 
also very apt to become the seat of diphtheritic infection. 

The infection manifests itself by a serous, turbid or purulent, 
sometimes fetid exudation with swelling of the affected surface, a 
purplish reddening and local pain; this surface becomes ulcerated in 
places; the appearance of a buff -colored false membrane is common, 
but it may be absent. Extension is rapid at times and sometimes 
occurs in form of a pseudo-membranous epidermic elevation, with 
centrifugal extension and polycyclic contours ; or it may result from 
the coalescence of aberrant vesicular lesions, at other times the patch 
remains stationary. Fever is not constant; glandular enlargement 
is usually present; lymphangitis in the vicinity or erysipelas are not 
uncommon. 

In the primary cases, the objective features assumed by cutaneous 
diphtheria are very variable. The most ordinary form is that of 
impetigo, ecthyma or impetiginous eczema analogous with that 
described above. In other cases, vesicles have been noted resem- 
bling those of varicella or the vesicle of dermatitis herpetiformis 
(Dawson), or bullae like those of epidemic pemphigus of the new- 
born or ulcers with distinctly circulate margins, abscesses and 
gangrenous patches; exceptionally the lesions may be of different 
types in the same patient. 

In connection with this polymorphism, it is noteworthy that 
cutaneous diphtheria is often not pure, either because it becomes 
grafted on a preliminary skin affection which has served as the 
infection-atrium, or because the diphtheria bacillus becomes asso- 
ciated with other microbes, notably streptococci and staphylococci 
as is commonly the case. Hence, even since the introduction of 
serotherapy, cases of cutaneous diphtheria with a fatal outcome 
are not very rare. 

Diagnosis. — Epidemiological factors, or the coexistence in the 
patient of a lesion of the neighboring mucous membranes, con- 
junctivitis, otorrhea, rhinitis, erosions of the buccal commissures, 
angina even if indefinite, vulvitis and balanitis, must arouse atten- 
tion. The demonstration of a false membrane on a dermic lesion 
is far from being conclusive. The key to the diagnosis is really 
furnished by the demonstration of the specific bacillus in smear- 
preparations, in cultures and by inoculation into guinea-pigs. 

The Loeffler bacillus is generally long, straight or slightly curved, 
in intermingled rods; it is Gram-positive; at its swollen extremities 
it presents metachromatic polar corpuscles, staining by the Neisser 
method; cultures on beef serum, at 98°, yield papular colonies of a 



596 INFECTIOUS BACILLARY DERMATOSES 

grayish white color in eighteen to twenty-four hours; it acidifies 
glucose culture-media; inoculated into guinea-pigs, it causes death 
in twenty-four to seventy-two hours. 

The pseudo-diphtheritic bacillus of Hofmann, from which it must 
be distinguished, is shorter, ovoid, has no distinct polar bodies, does 
not acidify glucose media and, most important, does not kill guinea- 
pigs. The fusiform bacillus of Vincent is Gram-negative. 

Treatment. — Even in merely suspicious cases, pending the diag- 
nosis, prophylactic measures for the avoidance of contagion are in 
order. The injections of antidiphtheritic serum have entirely 
changed the prognosis of diphtheria; large doses should accordingly 
be employed. As an accessory measure, the lesions must be carefully 
cleansed and local applications be made in conformity with the 
dermatological type and with the supposed microbic associations. 
The physician will accordingly prescribe for example, in a given 
case local applications of hydrogen peroxide water, or strong dis- 
infectants; moist antiseptic or rather cytophylactic dressings, or 
dressings with polyvalent serum, etc. 

SOFT CHANCRE. 

Soft chancre, simple chancre, or chancroid [ulcus molle] is a specific 
and contagious ulceration due to inoculation of the bacillus dis- 
covered by Ducrey (1899) and investigated by Krefting, Unna, 
Xicolle, etc. This bacillus is a short rod with rounded extremities, 
which appears separately, in groups, or frequently in small chains, 
whence the name of streptobacillus; it is stained with carbol blue, 
dilute Ziehl's solution, etc.; it is Gram-negative; often only its two 
extremities take the stain. Its culture requires special conditions 
and was for the first time successfully obtained by Langlet on a 
medium made of peptonized human skin; Besancon, Griffon and 
Le Sourd obtained cultures on blood-agar. The streptobacillus can 
be inoculated into various species of apes. It possesses a striking 
resemblance to the bacillus of bubonic plague. 

Soft chancre almost invariably results from direct venereal con- 
tagion, through the deposit of chancroid pus on some traumatic or 
pathological erosion during sexual intercourse; more rarely it is 
derived from an indirect contagion. 

The frequency of soft chancres in the same country or the same 
city is subject to very considerable fluctuations. A preceding 
attack confers no immunity, as illustrated by countless positive 
inoculations which have been obtained on the same individual. At 
the time when the single or dual character of chancre virus was still 
a matter of controversy, erroneous hopes were entertained of a 
possible vaccination against syphilis by means of this so-called 
syphilization method. 



SOFT CHANCRE 597 

The bacillus grows at the site of the infection, or inoculation for 
diagnostic purposes in doubtful cases, the lesions developing without 
any incubation, they are already characteristic at the end of twenty- 
four or forty-eight hours or three days at most. 

An incipient chancre presents the appearance of a vesicopustule 
with an inflammatory areola; on removal of its covering, a conical 
ulceration is exposed which penetrates deeply into the cutis. Spon- 
taneous auto-inoculations, notably on the labia majora and in the 
intergluteal fold often manifest themselves as small perifollicular 
pustules which have been named chancroidal folliculitis or miliary 
chancres. 

Papular chancre is a rare variety, but useful to know; it appears 
as a flattened or slightly acuminate papule with a soft base. 
Papular chancres are often multiple and may disappear after a short 
time, or they may become crested with a vesicopustule followed by 
ulceration. In the folds of the vulva and anus, simple chancres may 
assume the form of ulcerative and suppurating fissures. 

The mature chancre (p. 281) rarely attains or exceeds the size 
of a 5-cent piece. At the end of a period varying from two to six 
weeks, it loses its virulence, discharges less abundantly, granulates 
and heals spontaneously. Exceptionally, soft chancres are met with 
which persist several months without progressing and seem to be of 
attenuated virulence although still capable of auto-inoculation. 
Soft chancre always leaves a cicatrix with sinuous outlines, which 
may be smooth or honeycombed. 

No general disturbances from chancroidal infection are known, 
the disease being purely local. However, various complications 
may occur. The most common of these is suppurating chancroidal 
bubo; walking, fatigue and absence of local cleanliness are predis- 
posing factors. From the onset, during the course, or even after 
cicatrization of the chancre, the corresponding gland becomes 
swollen, the tissues are congested, fluctuation may appear and unless 
treated, spontaneous rupture takes place through a dark red and 
thinned skin. The pus of this bubo, contrary to the view of Straus, 
is virulent from the beginning and contains the bacillus. Sponta- 
neous ulceration of a bubo ordinarily assumes a chancroidal character, 
that is, the skin becomes detached and sinuous burrows as well as 
secondary fistulas are formed. This likewise occurs, although less 
frequently, in case of surgical incision. 

Gangrene of the prepuce and a portion of the sheath of the penis 
is occasionally observed in the course of subpreputial chancres. 

At the anus, soft chancre generally gives rise to an elevated con- 
dyloma (chancre in the form of pages of a book) ; it may invade the 
anal canal (chancroidal anitis of Ravaut and Bord, 1909), causing 
painful and bloody stools. 

Phagedena is a rare but formidable complication (p. 293). 



598 INFECTIOUS BAClLLARY DERMATOSES 

Histology shows soft chancres to consist of a loss of substance of 
the epidermis and the cutis; it is covered with a layer of pus contain- 
ing streptobacilli; it presents radiating processes which fissure the 
floor and the borders. Beyond this layer is a dense infiltration of 
well developed plasma cells. The bloodvessels show very pro- 
nounced changes of endoperivasculitis. The lymphatics are dilated. 
The ulceration results from a sort of digestion of the tissues under 
the influence of the parasite. 

If the treatment of soft chancre is to he efficient, it must not 
be limited to applying a little iodoform or a caustic agent to its 
surface. The ulcer must first be cleansed every day and carefully 
dressed; this is accomplished by means of cotton wipes or rolls 
dipped in soapy water, alcohol, or benzine and not until then 
is the alterative topical agent to be applied. The best is iodoform 
as a powder or iodoform with an addition of camphor (2 to 5 
per cent.); it rarely causes dermatitis provided care be taken to 
deposit it only in the ulceration itself; its persistent and suggestive 
odor has led many physicians to employ substitutes (iodol, diiodo- 
form, aristol, europhen, airol, etc.), but none is so efficient. The odor 
of iodoform can be concealed to some extent by an addition of 
coumarin or even of powdered roasted coffee beans. Almost equally 
valuable is silver nitrate in aqueous solution (1 to 15), in customary 
usage; or pure liquid carbolic acid which may be used only with 
extreme caution; carbolic acid has also been recommended, in 
alcoholic solution (10 per cent.), as well as ferropotassic tartrate 
(15 per cent.) and potassium permanganate (from 2 to 4 per cent.). 
The borohypochlorite powder of Vincent seems to be greatly supe- 
rior. A small cotton dressing must be applied. 

The virulence of the streptobacillus is destroyed by heat, so that 
very hot local baths should be prescribed, to be repeated at least 
two or three times a day, or preputial irrigations, or continuous 
applications of compresses soaked in hot boiled water (42° to 45°). 
Audry recommends the employment of radiant heat of the thermo- 
cautery brought within a few millimeters of the ulceration until its 
surface is dried out. A superheated air apparatus is still more con- 
venient. This procedure, which should be carried out two or three 
times, is somewhat painful but very effective. 

Suppurating chancroidal bubos are sometimes aborted under the 
influence of rest in bed, hot compresses and compression bandages. 
In case rupture appears inevitable, a careful incision may be made or, 
better, filiform drainage with two threads established; irrigations are 
applied every day until the discharge becomes merely serous, using 
a silver nitrate solution (1 per cent.) or a suspension of iodoform. 
Chancre of the anus is treated by means of wicks covered with a 
layer of iodoform-vaseline. 



CHAPTER XXVIII. 
DERMATOMYCOSES. 

The name of dermatomycoses must be reserved for diseases 
developing in the skin or reaching the cutis secondarily and caused 
by vegetable parasites of a higher order in the scale than the schizo- 
mycetes or bacteria. I separate these from the epidermomy coses 
which have already been discussed (Chapter XXV). 

After actinomycosis (the first known type in this category) and 
Madura foot, which is related to it, the investigations of American, 
French and German observers revealed the blastomycoses, and 
finally the sporotrichoses, discovered in America, studied more 
particularly in France in the last ten years and found in nearly all 
the countries of the earth. 

It is an established fact that the place occupied by the mycotic 
infections in human and animal pathology is decidedly larger than 
was formerly believed. Their knowledge is not only of scientific 
interest but also possesses considerable practical and therapeutic 
importance. 

The clinical manifestations of the dermatomycoses are poly- 
morphous and often ambiguous; laboratory investigations, notably 
cultures, are indispensable for a positive diagnosis and for identifi- 
cation of the pathogenic agent. This explains why our acquisitions 
in this domain are of relatively recent date and as yet incomplete. 
Moreover, it has been recognized that almost identical clinical 
pictures may be produced by different species, while inversely para- 
sites of the same group give rise to dissimilar affections. Accord- 
ingly there is no conformity between the pathology and the botanical 
classification. The latter is moreover still in the tentative stage in 
regard to the lower fungi and not definitely established. 

The following according to E. Pinoy are the botanical groups from 
which the principal dermatomycoses are derived: 

Nocardia (actinomycoses, mycetomas) ; Cohnistreptothrix (actino- 
mycosis); cryptococcus (blastomycoses); oidium (blastomycoses); 
madurella (mycetomas); sporotrichum (sporotrichoses); sacchar- 
myces (blastomycoses); and aspergillus (mycetomas). 

ACTINOMYCOSIS. 

The parasite which causes so-called "lumpy jaw" in cattle, known 
in France as sarcoma of the bovine maxilla, was named actinomyces 



000 



DERMATOMYCOSES 



by Bollinger. It gives rise in man to suppurating neoplasms and 
gummous formations. It appears in the pus or in the tissues in the 
form of yellow granules, from T V to 1 mm. in diameter, opaque and 
of oily consistence; they can be seen with the naked eye in pus which 
has been crushed between two glass slides or diluted with water in a 
watch-glass. These granules are mulberry-shaped and composed 
of a fragmented feltwork of mycelium in their center from 1 to 2 /x 
in width and at the periphery by large club-shaped refractive 
swellings, resulting from degeneration of the filaments, arranged in 
contiguous rays (Fig. 170). These clubs are sometimes absent. 
Unlike the mycelium, thev do not stain by the Gram method and are 







_sa_ 



Fig. 176. — Actinomyces granule. After Pinoy, Bull, de 1'Inst. Pasteur, November 
15 and 30, 1913, xi. 



not present in the cultures. The latter show that two distinct species 
may be involved, differing in their cultures; either Nocardia bovis, 
growing readily, aerobic, not inoculable into animals; or Cohni- 
streptothrix Israeli, anaerobic, growing with difficulty and inoculable 
into the peritoneum of guinea-pigs and rabbits. 

Actinomyces live quite abundantly as saprophytes outside of the 
animal tissues. Alan is rarely attacked through contagion from 
herbivorous animals; as a rule he becomes infected in the same way 
as cattle, notably through grains of cereals which have wounded the 
skin or the mucous membranes or been carelessly swallowed. The 
habit of chewing herbs or bits of straw when strolling through the 
fields must be regarded as dangerous from this point of view. 



ACTINOMYCOSIS 



601 



Actinomycosis exists in all countries. In France, its relative 
frequency in the vicinity of Lyons was pointed out by Poncet, in the 
region of Bordeaux by Petzes. It is more common in Germany [and 
rather rare in America]. 

Clinical Forms. — Cutaneous actinomycosis, which alone is here 
considered, may be primary or secondary; that is, the skin affords the 
parasite an avenue of entrance which is rare, or of exit, which is 
frequent. The lesions are cervico-facial in at least two-thirds of the 
cases, or they may be thoracic or abdominal, or located at the anus 
or on the extremities. 




Fig. 177. — Actinomycosis of the cheek. 



At the onset there is a hypodermic nodosity, with a rose-colored, 
hardly painful deeply adherent surface; the center of the mass 
promptly softens and becomes fluctuating; the purplish skin gives 
way and permits the escape of a small amount of purulent or 
sanious fluid, containing yellow granules. At the same time, other 
nodules have formed nearby which collect into patches and follow 
the same course; the ulcerations remain fistulous and granulating. 
(Fig. 177). 

There is presumptive evidence of actinomycosis when lesions 
presenting the following clinical features are encountered : nodosity 



602 DERMA TOM YCO&M& 

followed by a Conglomerate tumor of woody hardness, often deeply 
adherent, with a purplish surface, containing foci of a slowly gather- 
ing gummous pus; absence of corresponding glandular enlargement; 
tendency of the newfonnation to invade all tissues indiscriminately, 
the muscles, the vessels and even the hones. 

These characteristic features usually suffice for the differential 
diagnosis from dental abscesses, chancroids, lupus and tubercu- 
losis verrucosa, tuberculo-gummous syphilides, epithelioma, sporo- 
trichosis, etc. The demonstration of the yellow granules will supph' 
the necessary confirmation. Sero-agglutination and the fixation test 
have yielded results, but these are not reliable. 

Pathological Anatomy. — The parasite stimulates leukocytosis and 
proliferation of the fixed constituents in the form of nodules. The 
latter are accordingly formed in their center of an actinomyces 
granule in an amorphous necrotic zone, often surrounded by a 
wreath of giant cells; next by a zone of plasma or epithelioid cells; at 
the circumference there is a more or less considerable infiltration of 
leukocytes and swollen connective-tissue cells which insinuates itself 
between the connective-tissue bundles. The last-mentioned zone is 
of fibro-sarcomatous appearance and of a hard or lardaceous con- 
sistence. The vessels are often intact. 

Treatment. — Medication with potassium iodide, introduced by 
Thomassen, has markedly improved the otherwise very gloomy 
prognosis of actinomycosis. Failures do occur, however. The cus- 
tomary dose is at least 6 grams daily; Pinoy recommends in addition 
a salt-free diet and multiple deep cauterization of the lesions. In 
recent and not very extensive cases, a cure may be obtained in a 
few weeks. Local iodide injections are also administered. Radio- 
therapy seemed to me to exert an evidently favorable effect. 

Long-standing, deep and complicated cases require daily doses of 
to 12 grams of iodide and moreover the surgical removal or curet- 
ting of the foci. 

MYCETOMA OR MADURA FOOT. 

This disease, which is endemic in India, Western Africa, Morocco, 
etc., is due to several species of mucedinese, which penetrate into the 
organism by means of a foreign body such as thorns or splinters of 
wood, especially in bare-foot natives. The forms of nocardia, 
madurella mycetomi and Tozeuri have been recognized; Ch. Xicolle 
grew cultures of an aspergillus inoculable into pigeons (Pinoy). An 
analogous affection has been observed in America. 

Beginning on the sole of the foot, nodosities make their appear- 
ance which soften and discharge a sanious fluid containing granules 
of parasites; these granules are white, red or black, which has led to 



BLASTOMYCOSES 603 

three varieties of mycetoma being described. They consist of a 
mycelial feltwork without clubs. Through the growth and multi- 
plication of the nodes, the foot becomes deformed, globular and 
assumes an elephantiastic appearance while covered at the same 
time with bulla? or tubercles and hollowed by fistulous tracts; the 
leg on the other hand becomes wasted and atrophic. The glands 
are rarely enlarged. 

Iodide is not particularly successful and must be reinforced by a 
salt-free diet and cauterizations. The condition is relieved by the 
hyperthermic baths advocated by Legrain. Curative treatment 
must be surgical. 

BLASTOMYCOSES. 

Under this heading diseases are classified which are due either to 
yeasts or saccharomycetes or to parasites belonging to other botanical 
groups but which under certain conditions present themselves in the 
form of proliferating buds like the yeasts; the exact determination 
of the latter has not always been possible. 

The clinical appearance of the blastomycoses is very polymor- 
phous. To illustrate these cases, I shall limit myself to outlining 
the symptomatology of two of the best known types of the disease : 

1. Busse-Buschke Type. — This extremely rare type was very thor- 
oughly investigated and described by the authors whose names it 
bears; the cases of Ormsby-Miller, Curtis and Hudelo are appar- 
ently closely related to it. The pathogenic agent is probably a 
saccharomyees. 

The condition at the onset is marked by osseous and articular 
lesions; later on, or sometimes from the start, follicular inflammations 
develop or more often disseminated gummous nodules which become 
transformed into ulcers; their purulent contents and fungosities 
contain yeasts capable of cultivation and inoculation. The disease 
is febrile, taking a rather rapid course; the general health is gravely 
impaired. Death results from glandular and visceral lesions,. 

2. Gilchrist Type. — This form is said to be less uncommon; it 
was pointed out by Wernicke (1892), then by Gilchrist and Ricketts 
(1896) and was at first attributed to protozoa. About forty observa- 
tions have been published, the majority in America (Hyde, Mont- 
gomery, Stelwagon, etc.), and only five or six in Europe. The name 
of blastomycetic dermatitis is often applied to it. These dermatitides 
are due to two parasites which present a different appearance in the 
sections : an oidium Gilchristi in form of a yeast and a parasite with 
multiple external buds, coccidioides immitis. 

The lesions are dermic and begin on one of the extremities or on the 
face. A hard, reddish, superficial nodule becomes crusted with a 



604 



DERMATOMYCOSES 



yellow point and is transformed into a pustule discharging a thick 
viscid pus. The miliary abscesses increase in number, extend and 
give rise to an irregular, circumscribed papillomatous, erosive patch, 
infiltrated but movable on the deeper layers. The vegetating sur- 
face is interspersed with miliary abscesses, sometimes covered with 
crusts and may become partially cicatrized. The lesion extends 
superficially and the foci often multiply. The duration has fre- 
quently been from two to three years or longer. Spontaneous cure 
may occur ( Figs. ITS and 179). 






^ 










jj 


■ >sp 




mm 









Fi< 



Fig. 178 Fig. 179 

178 and 179. — Clinical types of cutaneous blastomycosis. (Ormsby.) 



Etiology. Without being as rare in Europe and notably in France 
as was formerly assumed, the various blastomycoses are nevertheless 
of very infrequent occurrence. In the lesions the parasites are seen 
as rounded bodies, measuring about 10/z, composed of a membrane 
with double contours and granular contents. They are more or less 
abundant in the sections and may be stained by the Gram-Weigert 
or other methods. Pus-smears should be washed in ether and 
examined in a solution of potash. 

The cultures in some cases grow readily on various media, notably 
on peptone-agar with glucose or maltose, preferably in the incu- 
bator; in other cases, they are only obtained with difficulty (Gil- 
christ type). The appearance of the colonies is variable and not 
very characteristic. The saccharomyces remain in the state of 
spherical or budding bodies of 2 jx to 20 fj, diameter; the oidia form 
mycelial-filaments in their cultures. 

Inoculation of some yeasts is successful in mice, young guinea- 
pigs and sometimes in dogs, yielding a sort of pseudotuberculosis. 



SPOROTRICHOSES 605 

Man can certainly be infected through the skin and perhaps also in 
other ways. It must not be overlooked that various species of 
mucedinese may be found accidentally on the skin or may live there 
as saprophytes; they may secondarily infect pathological lesions of 
various kinds. Great caution is therefore necessary in the inter- 
pretation of their pathogenic value. 

The several serodiagnostic tests which have been tried do not 
yield constant or altogether reliable results. 

Pathological Anatomy. — In the first-named clinical type, there 
exists a granulation-tissue rich in vacuolated giant cells packed with 
parasites. 

In the pustulo-vegetative type, intra-epidermic abscesses are 
demonstrable and in the cutis a superficial infiltration is seen formed 
by various cells, notably plasmocytes with rare giant cells. The 
proliferating epidermis sends branching proliferations hollowed by 
miliary abscesses into the depth of the tissue. In a general way, 
the appearance resembles both tuberculosis and epithelioma. The 
parasites are scattered and are found especially in the abscesses. 

Diagnosis. — Vegetative syphilides are less irregular in form and 
have fewer miliary abscesses. Papillary epithelioma has a hard 
consistence, friable proliferations and whitish masses formed of 
epithelial cells. The resemblance to tuberculosis verrucosa may be 
perfect; Gilchrist described his case as pseudolupus verrucosus. 
The blastomycoses are perhaps less purplish and less painful, more 
extensive and with more numerous foci. 

In suspected cases, aside from examinations of the pus, biopsy 
and cultures, it is advisable to inoculate guinea-pigs for the discovery 
of tuberculosis and to perform the Wassermann test for the elimina- 
tion of syphilis. 

Treatment. — The blastomycoses are grave affections requiring 
energetic treatment. Iodides have proved remarkably successful 
but must be given in large doses, from 6 to 8 grams daily and long 
continued. Local surgical treatment is sometimes imperative. 
Dressings with iodine solutions should be applied. 

SPOROTRICHOSES. 

The sporotrichoses are by far the most frequent dermatomy coses. 

For the first reported cases credit is due to Schenk (1899) and 
Hektoen and Perkins (1900) ; but for our knowledge of the mycoses 
in general and sporotrichosis in particular in all its forms we are 
indebted mainly to French contributions, particularly those of 
de Beurmann with Ramond (1903) and especially with Gougerot 
(1906-1912) whose work drew attention to this subject. 

The sporotricha are mucedinese, namely lower filamentous fungi. 



606 DERMATOMYCOSES 

with a creeping, regular, branching, partitioned or continuous 
mycelium bearing numerous short sporulated branches. The spores, 
measuring from .'J to <»m originate separately or in groups of two, 
either on the filaments or more abundantly on the conidiophorous 
branches. It is not known if these parasites do not possess higher 
fructification-forms. 

Among the pathogenic species, the best known and the most 
frequent is the sporotrichum Beurmanni, which I shall utilize as the 
type, the sporotrichum Schenckii differing from it in its faintly 
colored or white cultures and various other features; the sporo- 
trichum Dori is readily distinguished from it. 

The culture method is the procedure of choice for the demonstra- 
tion of these organisms; the technic of de Beurmann and Gougerot 
is simple and easy. Streaks of the pus on unsealed peptone-glucose 
agar tubes at room temperature yield at the end of six or eight 
days visible cultures which by the twelfth day have become exuber- 
ant and are often pure from the start. The method of Gougerot, 
which consists in dropping some of the pus on the glass of the tube 
or on the border of the agar, often permits a rapid diagnosis, in two 
or three days, by the demonstration of small gray filamentous stars, 
visible to the naked eye, or with the microscope through the culture 
tube; incubated at 98° the growth is less abundant. Other culture- 
media, notably carrots with glycerine, may be utilized. The whitish 
and acuminate colonies gradually turn brown, spread out and 
convolute on their margins, which are surrounded by a flat, finely 
radiating areola. These chocolate-brown cultures are characteristic. 

Inoculations into animals have yielded inconstant results; the 
virulence is slight. De Beurmann and Gougerot have obtained 
systemic infections; mice are the most suitable animals. 

The portals of entry in man escape observation; sometimes a 
previous traumatism has been noted at the affected point; infec- 
tion seems to occur especially by way of the mouth. [A laboratory 
worker in Chicago was accidently infected on the conjunctiva.] 

Symptoms. — The sporotrichoses are in the highest degree syphiloid 
or tuberculoid. However, their tissue and their pus are not inocul- 
able into adult guinea-pigs, which are susceptible to tuberculosis; 
they are not influenced by mercurial treatment; left untreated, they 
persist and multiply, whereas they are often readily curable by iodide 
t reatment ; finally, they contain a special parasite. This combination 
of features suffices for their recognition as a distinct entity. 

The disease is extremely polymorphous in its manifestations; the 
following are the principal clinical types: 

I. The disseminated gummems form; the gummas (p. 270) maybe 
softened but not ulcerated; or ulcerative, ulcero-vegetative, ecthy- 
matiform; they may assume to the highest degree a syphiloid or 



SPOROTRICHOSES 607 

tuberculoid appearance; or in other cases that of large more or less 
multiple abscesses. 

2. Lymphangitic form (Fig. 180), consisting of lesions of the pre- 
ceding type in chain-like arrangement above an initial "sporo- 
trichotic chancre;" this form is encountered especially on the limbs 
and sometimes on the head. 

3. Extracutaneous forms, affecting the bones, the synovial mem- 
branes, the testicles and the viscera; it is especially useful to be 
familiar with primary sporotrichotic osteitis which has been not 
infrequently observed, for example on the calcaneum; it gives rise 
to bone-liquefying abscesses and then to fistulas with secondary 
cutaneous lesions. 




Fig. 180. — Sporotrichosis, lymphangitic form; of two and a half years' standing; 
positive culture; cure in three weeks by potassium iodide. 



4. Ulcerative forms of the mucous membranes, localized in the 
mouth or pharynx, may extend to the base of the tongue, the larynx 
and the trachea; these cases are rare but extremely grave. Sporo- 
trichotic ulcers of the mucous membranes are distinguished by their 
prominence, their dirty yellowish-gray color, the absence of false 
membranes on their surface, their tendency toward diffusion rather 
than deep destruction and mutilation. 

Sporotrichotic cicatrices resemble those of syphilitic or tuber- 
culous ulcers; their borders are often irregular and ragged, some- 
times showing loosely joined tongue-like processes. 

Diagnosis. — The clinical picture may furnish highly suggestive 
evidence; in the St. Louis Hospital, sporotrichosis is usually recog- 
nized at first sight. The diagnosis is based on: the multiplicity 
and polymorphism of the lesions, which taken as a whole justify a 
diagnosis neither of tuberculosis nor of syphilis; their more acute 
course than that of the cutaneous tuberculoses; the viscid whitish 
pus which escapes from the softened nodules; the inconstancy of 



608 DERMATOMYCOSES 

glandular enlargements; and the preservation of good general 
health. 

Two scientific diagnostic procedures are available, however, 
which are indispensable in doubtful cases, which are very common: 
(1) Culture, which requires from eight to twelve days; (2) sporo- 
agglutination, discovered by Widal and Abrami, which furnishes 
immediate information; it is of value only when positive and at a 
very high ratio, at least 1 to 200. The serum of patients suffering 
from actinomycosis or thrush, etc., may also agglutinate a sporo- 
trichum culture, but at a greatly lower ratio. 

The reactions after cutaneous or subcutaneous injection of sporo- 
trichum emulsion may confirm the diagnosis, but do not establish 
it by themselves alone, on account of the possibility of associated 
reactions due to other mycoses or even to the presence of simple 
saprophitic yeasts in the patient's throat. It goes without saying 
that a negative Wassermann reaction, proving the probable absence 
of syphilis and the negative outcome of inoculation of diseased 
tissue into guinea-pigs, showing the absence of the Koch bacillus, 
are signs indirectly capable of corroborating a suspicion of mycosis, 
but insufficient for the determination of the special agent. 

Pathological Anatomy. — The histological lesions of the sporo- 
trichoses are not more characteristic than their clinical appearance. 
They consist of a nodular inflammation with a suppurative center. 

According to the general formula of Gougerot, the sporotrichotic 
nodule is formed by three concentric zones: at the periphery it is 
syphiloid, due to its subacute perivascular inflammatory character, 
with inconstant connective-tissue reaction and mononucleosis with 
plasmocytes; the middle zone is tuberculoid, through its epithelioid 
tubercles arranged around giant cells; the center is suppurative, 
with polynuclear and macrophagic cells. The majority of the 
tubercles originate from a proliferation of the vascular walls. 

One must not expect to find branching and spore-bearing myce- 
lium in the sections or in the pus; the only findings, which are more- 
over not constant, are short filaments or rather " navicular" bodies, 
free or contained in phagocytes. 

Prognosis and Treatment. — Left untreated, the sporotrichoses 
persist and their foci increase in number. Under the influence of 
iodides they are curable in the vast majority of the cases in the space 
of a fortnight to two months. The non-ulcerated forms subside 
more rapidly than the others. The existence of a tuberculous or 
other cachexia, to which the sporotrichosis may be secondary, of 
course aggravates the prognosis. The case observed by Letulle- 
Debre [pharynx, etc.] terminated in death. 

Potassium iodide should be administered in daily doses of 5 or 6 
grams, or more if tolerated by the patient; it is advantageous to 



SPOROTRICHOSES 609 

combine with it a salt-free diet; other iodides or injections of iodized 
oil may be utilized as substitutes in case of intolerance. Locally, 
it is necessary to puncture the purulent collections and to inject 
them with a 1 per cent, iodo-iodide solution; the ulcerations should 
be dressed with the same solution. The treatment should be con- 
tinued even after an apparent cure has been obtained and be renewed 
on the slightest threat of a relapse. 



CHAPTER XXIX. 
INFECTIOUS DERMATOSES DUE TO PROTOZOA. 

Up to a few years ago it was assumed that all infectious diseases 
were caused by bacteria or by lower fungi closely related to the 
Schizomycetes; those in which the organism had not been found 
were attributed to unknown bacteria. 

The discovery of the trypanosomiases, then of the parasite of 
syphilis, the other spirochetoses, leishmanioses, etc., has opened a 
new chapter, to which in all probability additions will be made in 
the near future. 

SYPHILIS. 

Syphilis — lues venerea, pox — is a systemic infectious disease, trans- 
missible by contact and congenital, due to the Spirochete pallida. 

It is extremely contagious and consequently very widely distrib- 
uted; it may affect all organs and all tissues without exception; 
give rise to symptoms of the greatest gravity such as cerebral 
syphilis, tabes, general paralysis, etc. ; and be followed by cancer of 
the mouth, abortion and a high infantile mortality. Thus it is only 
too true that syphilis is one of the greatest scourges of the human 
race. 

Infection usually takes place through the skin or through the 
mucous membranes and its most characteristic manifestations are 
exhibited on the external integument. Their description must 
therefore necessarily figure in a text-book of dermatology. The 
general picture of the disease will be given only in brief outline. 

Etiology. — In May of 1905, T. Schaudinn and E. Hoffmann 
reported the discovery in the contagious lesions of syphilis and in 
the lymph glands, of a parasite which seemed to be the long-sought 
causative agent of this disease. This has been definitely established 
by their later studies and by innumerable control investigations. 
The responsible organism had been seen a few years previously in 
a chancre, by Bordet and Gengou, who were not able, however, to 
follow it in the various syphilitic lesions. 

The parasite of syphilis, now classified under the name of Sjjiru- 
cheta pallida or Treponema pallidum is a protozoon of spirillary 
form, whose cylindrical body, of an average length of 6 to 14 ju 
and a width of at most 0.3yu, describes close-set narrow spirals, from 
six to twenty in number; it terminates at both ends in an extremely 
slender flagellum. An undulating membrane has so far not been 



SYPHILIS 611 

demonstrated. Living specimens on ultramicroscopical examination 
are seen to move actively for several hours. Some deviations from 
this typical appearance have been observed, possibly corresponding 
to developmental stages in a still unknown evolution. The trepo- 
nema for a long time was refractory to culture in any artificial 
culture-medium; Schereschewsky, W. H. Hoffmann, Sowade, 
Noguchi and others succeeded in growing it in pure culture under 
special conditions. 

The agent of syphilis can be stained with less difficulty than was 
originally believed. It is readily obtained in very thin smears of 
serous exudate or tissue-juice, fixed by heat, washed repeatedly 
for three or four minutes with a boiling mixture of the following 
composition: To 9 c.c. of distilled water add 2 drops of a 1 per cent, 
solution of potassium carbonate, and 2 drops of neutral glycerine; 
heat to the boiling-point and add 10 drops of Giemsa's eosine-azure ; 
the specimen must be very carefully rinsed in running water before 
it is dried and examined. Burri's method is also very convenient: 
the exudate is mixed on the slide with a small drop of India ink, 
spread out in a very thin layer, allowed to dry in the air and then 
directly examined in immersion oil ; the parasites stand out white on 
the dark background. In the tissues the parasite is demonstrated 
by means of the silver reduction methods devised by Levaditi. 

The spirochetes are constantly present in very large numbers in 
the chancre. They are also found in the glands and in great abund- 
ance in mucous patches and recent papules of all kinds; they are 
less frequent in the roseolar spots, a blister produced by the applica- 
tion of a fly-plaster to a papule often contains many spirochetes. 
Spirochetes have been found in the spleen (Schaudinn), in the supra- 
renal capsules (Jacquet and Sezary), and in the meninges. Their 
usual presence in the blood during the active stages of the disease 
has often been demonstrated, especially indirectly; in the cerebro- 
spinal fluid, the seminal fluid, the milk and the urine, the parasite 
of syphilis is found only under special and exceptional conditions. 
They are very rare in tertiary lesions, but Noguchi and several 
investigators after him found spirochetes in the brains of patients 
who had suffered from general paralysis. They are very abundant 
in children and fetuses with congenital syphilis, notably in the liver, 
the spleen, the suprarenals, the lungs, the blood, as well as in the 
cutaneous lesions. The parasite has been successfully followed in 
serial inoculation into monkeys and more recently also other animals. 

Syphilis was for a long time considered as absolutely peculiar to 
man; it was taught that neither race nor age nor sex confer immunity 
against it, but that a first attack renders the patient permanently 
immune. More recently it has been recognized, however, that the 
immunity acquired by a first infection may not always be absolute 



612 INFECTIOUS DERMATOSES DUE TO PROTOZOA 

and permanent; the possibility of reinfection lias been demonstrated 
in some cases, not numerous but convincing. 

On the other hand, two years before the discovery of the spiro- 
chete (July 28, 1903) Roux and Metchnikoff showed that syphilis 
is inoculable into anthropoid apes; Lesser, Xeisser and many others 
confirmed these observations. Since that time it has been recog- 
nized that inoculation is also successful in the lower monkeys; an 
attempt has been made to utilize this fact for diagnostic purposes, 
a procedure which actually possesses but small practical value. 
More recently syphilis has been successfully inoculated into rabbits, 
dogs, guinea-pigs and sheep. Inoculation into the rabbit's cornea 
(Bertarelli) or on the scrotum of this animal (Parodi) has so far 
yielded most positive results; their proportion is increased in serial 
reinoculations and sometimes symptoms of generalization have been 
noted. Experimental syphilis has already led to valuable scientific 
findings and is sure to furnish a further abundant harvest. 

According to the classical teachings, there are two modes of con- 
tracting syphilis: by contagion or by heredity. 

Acquired syphilis results from a venereal or accidental contact, 
which may be direct or indirect; congenital syphilis is present at 
the birth of the child and is derived from its parents. 

Acquired Syphilis. — The course of acquired syphilis is subject to 
certain laws. The infecting contact is followed by a latent period 
known as the first incubation, usually lasting twenty-five days, 
sometimes shortened to ten or fifteen days or very exeeptionally 
prolonged to sixty and even to ninety days. Then the primary mani- 
festation makes its appearance at the point of the inoculation itself, 
as the syphilitic chancre with which at the end of about a week a 
satellite bubo becomes associated, constituting the primary stage. 

Next follows another latent period, the second incubation, of an 
average duration of forty-five days, at the end of which the secondary 
symptoms appear; these are of various forms, scattered and profuse, 
usually showing a benign behavior and located especially on the skin 
and the mucous membranes; as a rule they recur during several 
months, or sometimes during two or three years or longer when the 
disease is left to itself or is insufficiently treated. 

Later on, especially after the fourth year, sometimes earlier, and 
often at remote dates of ten, twenty or thirty years or still later, 
the tertiary symptoms may appear. While they have less tendency 
to diffusion than the secondary symptoms, they cause much deeper 
damage to the tissues in which they are situated. They may affect 
any organ, any apparatus, including the skin and the mucous 
membranes and notably the nervous system, the last-named locali- 
zation being especially formidable, 



SYPHILIS 613 

The primary lesion, the chancre, is practically never absent, but 
it may remain undetected, this being actually frequent in women. 
The few known cases of "immediate syphilis" (d'emblee) or "decapi- 
tated syphilis" in men are explained by very unusual conditions. 
In the absence of early and energetic treatment, the secondary 
manifestations are only very rarely absent. This remark does not 
apply to the tertiary symptoms, which develop preferably in tainted, 
intoxicated or exhausted individuals under bad hygienic conditions 
and especially in incorrectly or insufficiently treated patients. 

It is noteworthy that the secondary and tertiary periods are not 
always distinctly separated, neither in time nor by the character 
of the associated manifestations, but may widely encroach upon one 
another [or overlap]. This subdivision is nevertheless justified by 
the course of the majority of the cases and, moreover, is convenient 
from the didactic point of view. 

Syphilis may finally eventuate in remote sequelae which are not 
influenced by antisyphilitic treatment. A. Fournier designated 
these as parasyphilitic symptoms and interpreted them as indirect 
consequences of syphilis. This group (general paralysis, tabes, 
leukoplakia, aneurysms, etc.) will undoubtedly have to be rear- 
ranged, for the presence of spirochetes in the brain of paretics shows 
that in these cases at least, genuine syphilis is responsible [and this 
is certainly true also for tabes and aneurysm]. 

Among all the symptoms of syphilis, only the primary chancre 
and the secondary or tertiary lesions involving the skin and the 
mucous membranes enter into the scope of this book. These sec- 
ondary and tertiary cutaneous or mucous manifestations are 
generally designated under the name of syphilides. 

Syphilitic Chancre. — Also known as hard chancre [ulcus durum], 
primary lesion, initial sclerosis. The syphilitic chancre develops at 
the point which has served as the infection-atrium of the virus. It 
suffices that living treponemata derived from a contagious syphilitic 
lesion be deposited upon a traumatic or pathological lesion, ulcer- 
ation, herpetic erosion, fissure, or even a trifling excoriation, to 
bring about the infection; it is not probable that they can pass 
through the intact epidermis, but they may possibly pass through 
the intact epithelium of mucous membranes. Transmission usually 
takes place directly, through sexual intercourse, kissing, accidental 
or occupational contact; much less commonly through the inter- 
mediation of some contaminated object. 

During the first incubation, the lesion which has served as the 
infection-atrium has usually had ample time to disappear. The 
parasite multiplies locally at first without producing a demon- 
strable reaction and already begins to spread in the organism 
through the lymphatics and the veins; indeed, an early excision 



fil4 



INFECTIOUS DERMATOSES DUE TO PROTOZOA 



of the incipient chancre, for the purpose of aborting the syphilis 
is almost invariably unsuccessful. The production of immunity 
is not immediate, however; the chancre is often auto-inoculable 
during the first eleven days following its appearance, according to 
Queyrat; this would serve to explain the cases of successive multiple 
chancres. 

An incipient chancre, better known through experimentation 
on monkeys, presents the appearance of a very small slightly 
papular red spot, or in other cases a scaly crust covering a super- 
ficial erosion. The erosion and induration keep on progressing until 
in a few days the primary sore (Fig. 181) has assumed the six follow- 
ing characteristics, as clearly pointed out by A. Fournier: 




Fig. 181. — Syphilitic chancre of the sheath of the penis, of five weeks' standing; 
untreated. 



(1) It is a slight erosion, generally of the size of a dime [about 
1 cm.], not an ulceration; (2) it has a round, regular, orbicular 
form; (3) without marked borders, that is, without prominence, 
perpendicular depression or detachment, its surface being on the 
same level as the surrounding tissues or sometimes slightly convex 
or depressed; (4) of a color varying from red, flesh-color with 
smooth, moist and glazed or finely granular surface, to a grayish 
color with diphtheroid surface scattered with ecchymotic points and 
sometimes covered with a thin brownish crust; (5) an indurated 
base, which is recognized by grasping the chancre between the 
thumb and index finger, across its diameter and slightly raising it; 
thereby demonstrating a characteristic, circumscribed and dry 
hardness, of very variable thickness, sometimes superficial, like 
parchment or paper, in other cases deep, resembling pasteboard, or 
nodular; (0) the chancre is accompanied by a satellite bubo. 

This bubo, which according to Ricord's expression follows the 



SYPHILIS 615 

chancre as the shadow follows the body, has its seat in the glands 
corresponding to the lymphatic territory of the chancre. It con- 
sists of a glandular constellation, namely a group of hard, ovoid, 
movable, painless and non-inflammatory glands; one or two of 
these glands are apt to be larger than the rest and may present a 
very evident protuberance. The bubo appears from six to ten days 
after the chancre and survives it as a posthumous witness for a 
number of months. 

The chancre itself heals in a fortnight to six weeks; the induration 
as a rule persists for several months, sometimes actually increasing; 
a cicatrix is seen in only about one-half of the cases. 

Exceptionally, an erosion known as chancre redux may reappear 
at the same point, after a very variable period. 

The varieties of syphilitic chancre are innumerable; but the 
typical form is by far the most common. 

There occur dwarf lenticular chancres, or giant chancres; papular, 
hypertrophic, or markedly ulcerative chancres, or echthymatous 
chancres covered with a fairly thick crust. Although hard chancre 
is, as a rule, solitary, multiple chancres to the number of two or three, 
or more, are encountered nearly as frequently and up to fourteen 
have been counted on the same patient; they are simultaneous or 
successive, which may be due to a variable incubation, successive 
contaminations, early auto-inoculations, or to a chancrous lymphan- 
gitis which has given rise to local erosions. 

Complications. — The onset of the chancre may be directly pre- 
ceded by a herpetic eruption, a common and serious source of error; 
this herpes runs the ordinary course, but one or several of the ero- 
sions become indurated, thereby revealing their chancrous character. 
The chancre is not uncommonly accompanied by a local and vo- 
luminous first soft then hard sclerotic edema, notably of the vulva 
or the prepuce (phimosis), which suggests its presence, although it 
helps to conceal it; the chancrous induration can be felt with the 
finger and confirms the diagnosis. The indurated chancre becom 3S 
inflamed after traumatism, improper treatment or secondary 
infection; it becomes painful, bleeds and suppurates; sometimes, 
the bubo itself undergoes a usually sluggish purulent disinte- 
gration. Superficial or penetrating gangrene and phagedena are 
rare complications. Mixed chancre, propounded by Rollet (Lyon) 
is more or less rare according to the environment and results from 
inoculation at the same point with the Ducrey bacillus and the 
treponema, their incubation being of very unequal length. When 
the infections are simultaneous, a soft chancre develops, then 
becomes indurated and opens again in case it was cicatrized; when 
the infection is successive, a soft chancre becoming grafted on a 
syphilitic chancre, it forms an ulcer in the preexisting induration. 



616 INFECTIOUS DERMATOSES DUE TO PROTOZOA 

Localization. — Genital chancre in men is more frequently located 
in the balanoprepntial groove and the sides of the frenum, but may 
occur on any other point of the penis, the scrotum or the pubis. 
Chancre of the meatus and intra-nrethral chancre, which are rare, 
manifest themselves by a serous oozing and a circumscribed indura- 
tion. In women, the labia majora and minora, the fourchette, the 
<lit oris, and more rarely the meatus, are the seat of the chancre; hardly 
ever the vagina. ( hancre of the uterine cervix would appear less rare 
if it were more frequently looked for; it presents itself in the form 
of a distinctly limited red or grayish erosion with a narrow red 
margin and an induration perceptible to the touch. [In rare cases 
it may become the site of cauliflower excrescences on the cervix.] 

Extragenital chancre is localized on the head in two-thirds of the 
eases, preferably at the mouth and especially on the lower lip; when 
it straddles the free borders of the lip, it is crusted in its cutaneous 
portion, erosive in its mucous portion. After chancre of the lips 
come in order of frequency, chancre of the tongue and chancre of the 
tonsils. The latter, which must not be confused with angina, nor 
especially with the fusospirillary ulceration of Vincent, is unilateral, 
erosive or ulcerative, nearly always diphtheroid, of woody hardness 
to the touch, gives rise to only slight pain, persists during four or 
five weeks and is associated with a usually enormous enlargement 
of the retromaxillary glands. Chancres of the chin, the eyelids, the 
conjunctiva, the nostrils, the gums, the scalp, etc., present no very 
specific features; [the associated adenopathy usually creates a 
suspicion of their nature]. 

On the upper limbs, chancre affects chiefly the fingers, the cir- 
cumference of the nails or the joints; it resembles a badly healing 
panaritium or a proliferating wound. This localization is not uncom- 
mon in physicians and midwives and the same is true for chancres 
of the eye. Vaccination chancre has become extremely rare since 
vaccination from arm to arm has been generally abandoned. 

Chancre is also frequently situated on the breast, notably in 
wet nurses. 

It is fairly common at the anus in both sexes and is here apt to 
assume the so-called book-leaf form. There is no region of the body 
in which its occurrence has not been noted. 

Extragenital chancres are usually the beginning of innocently 
acquired infections, syphilis insontium, comprising occupational 
syphilis, workshop epidemics (glass-blowers, for example), family 
epidemics and so forth. 

The frequency of extragenital chancres as compared to that of 
genital chancres is in the proportion of 1 in 8 or 9. The possibility 
of this occurrence must always be kept in mind so as to guard 
against error, which may have very serious sequela?. 



SYPHILIS 617 

Diagnosis. — In some cases the diagnosis of syphilitic chancre is 
evident from the start; in others, the objective features of the lesion 
merely justify a suspicion which requires to be confirmed; it is well 
to remember the possibility of chancre no matter what may be the 
patient's social standing or age or the seat of the suspicious lesion 
(extragenital chancres) . 

Even when the diagnosis is certain, it is advisable for reasons 
readily understood, to state the truth only guardedly and with the 
greatest circumspection to the patient. Where there is the least 
doubt, and in fact in all cases, it is important to control the objective 
diagnosis by what may be called the elements of the general diag- 
nosis of syphilis and especially by laboratory investigations. It 
would be a serious error to begin specific treatment before having 
absolutely proved of the existence of syphilis. 

The history, statements of a suspicious contact three or four 
weeks before the appearance of the chancre and confrontation in 
certain cases, possess only the value of highly probable arguments. 

The best and most practical procedure for scientific demon- 
stration consists in the ultra-microscopical examination of the serous 
fluid which has been squeezed out of the chancre after superficial 
scraping. 

For this examination to be valid, the patient must not yet have 
received specific treatment and no antiseptic or caustic application 
of any kind must have been locally employed in the last five or six 
days. The discovery of the characteristic spirochetes is conclusive; 
in case of failure, the examination should be repeated after a few 
days' interval [or should be repeated daily if necessary, the patient 
meanwhile covering the lesion with a moist dressing of normal 
saline solution]. 

The Wassermann reaction does not become positive until about 
the eighteenth day of the chancre. 

In Chapter XV {'passim) may be found the essentials of the differ- 
ential diagnosis of hard chancre and other analogous ulcerations. 
Briefly stated, the lesions of the genital region which most frequently 
lead to confusion with a primary sore are the following: 

Traumatic ulcerations are of more irregular form, non-indurated, 
without bubo. 

Herpes may mask an incipient chancre and must be watched; 
when it has been cauterized, treated with an irritative lotion, 
for example with perchloride of mercury, or with certain powders 
such as aristol, the herpetic erosion hardens, the glands become 
swollen and the aspect may be to the highest degree suggestive of 
chancre. After several days when the inflammation has subsided 
under the influence of rest, baths and moist dressings, the artificially 
induced difficulty will generally have disappeared; if necessary, an 
ultramicroscopic examination can be carried out. 



liiS INFECTIOUS DERMATOSES DUE TO PROTOZOA 

Soft chancre, with its perpendicular borders and its irregular and 
suppurating Moor, rarely causes difficulties; all doubts can be settled 
in forty-eight hours at most, by the discovery of the I hicrey bacillus, 
or better by auto-inoculation in the deltoid region. In case of mixed 
chancre, this auto-inoculation would be positive and the discovery 
of the spirochete practically impossible; under these difficult con- 
ditions, the appearance of a positive serum reaction often becomes 
the only practical way of settling the diagnosis. 

The name of chancriform syphiloma is applied to a lesion which 
may appear between the second and the fifth year, preferably at the 
point where the original chancre was located, the features of which 
it may closely reproduce; or it may be more irregular in contour and 
deeper. In all cases, there is no bubo, the Wassermann reaction is 
positive from the start and the antecedents are sufficient to post the 
physician. The interest of this manifestation lies in its frequently 
having given rise to the suspicion of a reinfection; it has been 
thought that it might sometimes be the result of a specific rein- 
oculation on an imperfectly immunized territory. 

The treatment of syphilitic chancre must be very simple; it is 
essential to avoid all irritation. 

Early excision under certain conditions still has its adherents; it 
will be discussed further on. 

Cauterizations, applications of mercurial, calomel, iodoform, etc., 
salves should be avoided; clean moist dressings, with glycerolated 
starch or borated vaseline are sufficient. 

Under the influence of energetic general treatment, a chancre will 
heal in less than ten days. 

Second art/ Stage. — From thirty-five to sixty days after the appear- 
ance of the chancre, generally at the end of forty-five days, the 
secondary symptoms develop. These are sometimes multiple, 
profuse and stormy, such cases being described as secondary ex- 
plosions. All possible degrees may occur between the nearly com- 
plete absence of all manifestations and the forms described as 
precocious malignant syphilis. 

The secondary lesions may affect a large number of organs or 
organic systems. Generalized glandular enlargement is never absent. 1 

Roseola, papular eruptions, mucous patches and headache, are 

1 The generalized adenopathy becomes progressively established in the course of the 
primary stage. In case of chancre of the genital region, the inguinal bubo appears 
from the ninth to tenth day after chancre; the cervical, supraclavicular, middle and 
suboccipital glands become perceptible to touch by the twelfth to fifteenth day; 
the cpitrochlear glands toward the eighteenth day. The value of the presence or 
absence of generalized glandular enlargement for the diagnosis of syphilis is con- 
siderable and too often overlooked; I have emphasized its importance for many years 
in my hospital service. 



SYPHILIS 619 

extremely common ; neuralgias, myalgias, arthralgias, deep bone-pains 
are frequent; alopecia, iritis, albuminuria, abortion, are not rare. 

The general condition is more or less disturbed; there often is an 
anemic pallor, with rather marked leukocytosis; loss of strength, 
anorexia, emaciation, neurasthenia, enlargement of the spleen. 

In women especially, fever with an irregular course may be 
observed; a typhoidal state ("typhose syphilitique") has even 
been described but such cases are probably due to superadded infec- 
tions. [In exceptional cases the temperature may reach or exceed 
104° F. (40° C,)]. 

These various secondary manifestations may becomes endlessly 
combined, their coincidence often facilitating the diagnosis. How- 
ever, in a fair number of cases the cutaneo-mucous eruptions or 
secondary syphilides which are alone to be described in this book, 
present themselves separately without other symptoms besides 
generalized glandular swelling. 

Secondary Syphilides. — Their general features are their poly- 
morphism, their abundance, their dissemination, their insidious 
non-inflammatory development, their painlessness and the complete 
absence of itching. 

The lesions are usually of a rounded form, sometimes arranged in 
rings, loops or clusters (See Fig. 39 and 127) ; their color is yellowish- 
red, like bacon, sometimes coppery, or of a so-called sombre hue. 
A development in successive crops, a tendency to spontaneous invo- 
lution and frequent recurrences complete their general properties. 

The eruptive lesions of secondary syphilides belong to four prin- 
cipal types: erythema (roseola); the papule; the ulceration; excep- 
tionally, the bulla (in congenital syphilis). 

These various morphological types may be seen in juxtaposition, 
constituting polymorphous eruptions. 

In a general way, however, one type almost invariably predomi- 
nates; I have described these eruptive forms in the first part of this 
book, to which the reader is referred; here it will suffice to retouch 
the picture. 

1. The erythematous syphilides are simple roseola, which is almost 
regularly the first eruption; and circinate roseola, delayed, recurrent 
and rebellious (p. 41). 

2. The papular syphilides, often precocious, include, according to 
the size of the lesions, a lenticular or common form (p. 142); a 
miliary form which is follicular and obstinate (p. 396); a nummular 
form (p. 144); and numerous morphological varieties: papulo- 
squamous or psoriatiform (p. 113); papulo-crusted (p. 172); and 
vegetative (p. 247). To the papular type should be annexed, in 
my opinion, the palmar and plantar keratodermic syphilides (p. 216), 
which may be precocious or delayed, but invariably rebellious. 



020 INFECTIOUS DERMATOSES DUE TO PROTOZOA 

3. The ulcerative syphilides are especially serious and constitute 
varieties which are malignant from the start (p. 286). 

4. The bullous -syphilides are peculiar to precocious hereditary 
syphilis (p. 177). 

This enumeration does not exhaust the list of cutaneous mani- 
festations of the secondary stage; there still remain to be mentioned: 

.">. Pigmentary disturbances (p. 320). 

6. Lesions of the adnexa, the hairs (p. 411) and nails (p. 436). 

It is important to note that these various types of lesions are 
characteristic only on the skin. On the mucous membranes and 
even on the epidermis in macerated regions, these types lose their 
distinctiveness and tend toward a more or less erosive and oozing, 
hence highly contagious common form, which is currently desig- 
nated under the name of mucous patch. 

Secondary Syphilides of the Mucosa or Mucous Patches. — This is 
the most common among secondary lesions and it may be stated 
that few syphilitics are exempt from it. Through their contagious- 
ness, mucous patches acquire social importance, for they are respon- 
sible for most transmissions. 

They usually appear after the first eruptive manifestation; 
they often recur repeatedly during the first two or three years; 
especially when provoked by local irritations — tobacco and a bad 
condition of the teeth for buccal or pharyngeal patches; uncleanli- 
ness for genital and anal patches. They have been noted in the 
sixth and eighth year and are held responsible for the very rare 
and extremely doubtful cases of syphilitic infection in the twelfth 
and even in the eighteenth year. 

Mucous patches may be situated at any point of the mouth, the 
lips, the isthmus and the pharynx, especially on the tonsils and 
faucial pillars, the commissure of the lips and in the vicinity of 
carious teeth; at any point of the vulva; on the prepuce and glans, 
around the anus, on the conjunctiva?, in the nasal fossse, in the 
larynx; sometimes even in the axilla?, at the umbilicus, or more 
frequently between the toes. The syphilides designated as mucous 
patches of the skin have been previously mentioned (p. 144). 

A distinction is made between several varieties of syphilides of 
the mucous membranes, which correspond to the cutaneous syphil- 
ides, representing a possible localization of the latter. 

Erythematous syphilides, simple red spots, are seen especially on 
the palate, on the cheeks and on the labia minora. 

Opaline plaques, ordinary mucous patches, the most widely dis- 
tributed variety, are characterized by a slight, sometimes hardly 
papular elevation, on which the epidermis is swollen and whitish, 
not eroded nor proliferating. They are encountered everywhere, 
notably on the velum of the palate or at the vulva; they may 
assume a fairly characteristic circinate arrangement, in arcades. 



SYPHILIS 621 

The pharyngeal and buccal mucous patches are sometimes 
diphtheroid, to such a degree that a confusion with diphtheria 
occurred in cases reported by Fournier. It is probable that this 
appearance is the result of a superadded infection (fuso-spirillary 
association, etc.). 

Erosive or papulo-erosive syphilides are papular syphilides whose 
squamous epithelium has become detached; they present the appear- 
ance of distinctly rounded red erosions; they often become, or have 
been opaline. The papular mucous patches are known outside of 
France as flat condylomata [condyloma latum]. 

Papulo-hypertrophic and proliferative mucous patches develop 
especially in uncleanly persons, at the vulva or in its vicinity, in 
the genitocrural and intergluteal folds and sometimes at the buccal 
commissures; on the tongue, notably on its posterior third, they 
may constitute what the French call "toad's back tongue." I have 
seen enormous patches of this kind on a wholly neglected scalp. 
They consist of elevations the size of a pea to that of the thumb or 
larger, sometimes nearly a centimeter thick, with a granular or 
papillomatous surface, discharging a turbid and yellowish serous 
fluid with a fetid odor. 

Ulcerative syphilides of the mucous membranes are less common, 
they are observed on the lips, at the commissures, the gums, the 
pharynx and on all parts of the vulva. 

Certain syphilitic lesions of the tongue known as smooth patches 
or "mowed-lawn" patches are usually regarded as related to mucous 
patches. These are dry, red, non-eroded patches deprived of their 
papilla?, usually of an oval shape; they may become papular. Their 
onset is often delayed and may even occur in the course of the 
tertiary stage; Fournier considered them as contagious. They 
are very slightly amenable to mercurial treatment and last several 
weeks or even months. 

Although usually painless, mucous patches may interfere with 
movements, causing dysphagia, etc. 

The diagnosis of mucous syphilides is easy when they occur in 
the course of a long train of symptoms; inversely, it frequently 
happens in practice that they furnish valuable information in 
doubtful cases; but it would be venturesome to base a diagnosis 
of syphilis exclusively upon the presence of mucous patches, even 
when they assume an appearance which may seem to be typical. 

The principal causes of error are as follows, in the mouth : aphthae 
are entirely round, yellowish with a narrow carmine margin and very 
painful. Herpes appears suddenly, is painful and polycyclic. The 
bullous dermatoses, hydroa, may produce lesions almost identical with 
mucous patches. Perleche is an opaline erosion situated exclusively 
at the commissures of the lips, but encroaching upon the cutaneous 



622 INFECTIOUS DERMATOSES DUE TO PROTOZOA 

epidermis of the vicinity; it is epidemic in schools and due to a 
streptococcus. Glossitis areata exfoliativa is characterized by its 
special border. Leukoplakia, buccal lichen planus and median 
rhomboidal glossitis, etc., are dry, stationary or very persistent 
lesions. Mercurial stomatitis is a diffuse inflammation, sometimes 
with peridental or lingual ulcerations closely resembling mucous 
patches; a coincidence is possible. 

Sources of error in the genital region are represented by: trau- 
matic lesions, which are irregular and ephemeral; erosive balano- 
posthitis, which is characterized by whitish circinate forms which 
may be removed by friction. 

Soft chancre is purely ulcerative and suppurates profusely; it is 
auto-inoculable. Proliferative herpes of the vulva, a very rare 
disease, closely simulates the papulo-erosive syphilides. The same 
is true for the post-erosive papular erythema of nursing infants 
(Fig. 1). Finally, in uncleanly individuals, one may see in the 
vicinity of the anus absolutely syphiloid patches of proliferative 
dermatitis, which are of commonplace character (A. Fournier and 
Brouardel). 

[The demonstration of spirochete pallida on the surface of a 
lesion of the mucosa is not always easy. When it can be made 
with certainty the diagnosis is placed beyond a doubt.] 

Tertiary Stage. — While it is possible to enumerate in a few lines 
the principal secondary syphilitic lesions and to give an idea of the 
course of this stage, such a sketch is altogether impracticable in 
regard to tertiary syphilis; its domain is too extensive, its course too 
varied and too irregular. I shall accordingly discuss only its cuta- 
neous and mucous lesions. 

Tertiary Syphilides.- — The general features distinguishing these 
from the secondary symptoms are as follows: They are deep and 
serious, not superficial and benign lesions, of an ulcerative or sclerotic 
type, not undergoing absorption; limited and regional, not profuse 
and scattered; monomorphous, often with a well-marked tendency 
to become arranged in groups and to assume a circinate configur- 
ation, "to become disciplined" to use an expression of Fournier's. 

The circinate or rather semicircular arrangement of an eruption 
would be incorrectly interpreted as characteristic of syphilitic 
lesions; in the first place, its constituent eruptive lesions must be 
taken into consideration. The following general statements can be 
made: While rare in secondary syphilis (syphilides in arcades, 
mucous patches in arcades), a circinate arrangement is very common 
in the tertiary syphilides. It is encountered furthermore in some 
cases of lupus, in some eczemas and psoriasis, in many erythemas, 
in recurrent pemphigus, sometimes in mycosis fungoides, in lichen 
planus, lichen scrofulosorum, parapsoriasis en plaques, etc. The 



SYPHILIS 623 

eczematides and more particularly the cutaneous trichophytosis, 
rather form complete circles. 

The question of the contagiousness of these tertiary lesions 
had been settled in the negative sense or very nearly so. Modern 
methods of investigation, however, notably inoculation into mon- 
keys, have shown that a certain number of these lesions are virulent, 
the proportion being difficult to indicate. We do not know if the 
spirochete, as has been supposed, exists here in a different form 
from that which it assumes in chancre and in the secondary mani- 
festations [but there is no necessity for this assumption; a gumma is 
the effect of a spirochete in loco acting on a soil modified by the 
existing disease. Spirochetes have been found in gummas though 
in very small numbers. I am of the opinion that encysted or rest- 
ing forms must also exist; but this lacks proof.] 

The morphological aspects under which the tertiary syphilides 
may manifest themselves have been previously described; they are 
classified under six headings, as follows : 

1. Tertiary erythemas (p. 41). 

2. Tubercular syphilides, circinate or in patches (p. 253). 

3. Ulcerative syphilides, of several varieties (p. 285); tuberculo- 
ulcerative, atypical gummous, sclerogummous and phagedenic. 

4. Syphilitic gummas (p. 267). 

5. Tertiary vegetative syphilides (p. 247). 

6. Diffuse hypertrophic syphilomas and syphilitic elephantiasis (p. 
368). 

These various lesions may occupy any region of the integument 
or of the mucous membranes. It may serve as a useful guide, 
however, to mention the types which occur especially in some special 
regions. 

The center of the face, the nose and the lips, is one of the elective 
foci of tertiary syphilis in all its forms, dry tubercular, ulcerative, 
proliferating and leontiastic. Superficial confluent tubercular syph- 
ilides, closely analogous to rosacea, are also observed in this location. 

In the mouth, on the palate and the pharynx, superficial tuber- 
cular and ulcerat ve syphilides are met with, as well as perforating 
gumma. 

On the tongue, there occur gummas, gummous and sclero- 
gummous infiltrations, sclerotic glossitis and sometimes tubercles. 

On the scalp, gummas and tuberculo-ulcerative syphilides are 
not uncommon; the crusted and superficial variety of the latter 
may simulate psoriatiform eczematides. To the palmar and plantar 
regions belong the psoriatiform so-called keratodermic syphilides. 
On the extremities, syphilitic elephantiasis may develop. On the 
external genital organs of both sexes, gummous infiltrations and 
gummas are found, as well as proliferative, chancriform, phage- 
denic syphilides, etc. 



624 INFECTIOUS DERMATOSES DUE TO PROTOZOA 

For the diagnosis of each of these forms, the reader is referred to 
the description of the eruptive lesion which distinguishes it (Part I, 
Morphology). 

Congenital Syphilis. The teachings on the subject of congenital 
syphilis and the multiple problems involved in its investigation 
have been greatly influenced by recent scientific acquisitions, the 
discovery of the spirochete and the introduction of the Wassermann 
test. Without entering into details, I shall limit myself to stating 
the conclusions which are agreed upon or at least tend to become 
generally accepted. 

Hereditary syphilis, better named congenital, is always of maternal 
origin; it is transmitted from the mother to the fetus by way of the 
placenta rather than through the germ-plasm or the ovum. 

As the mother of a child born with syphilis is always herself 
syphilitic, even if she appears healthy (Wassermann reaction), this 
fact affords a simple explanation of Colles' law (immunity of the 
mother of a child born with syphilis) and Prof eta's law (immunity 
of an apparently healthy child toward its syphilitic mother). So- 
called conceptional syphilis, or through reflex ("choc en retour") 
in utero (syphilization of the mother by a fetus conceived from a 
syphilitic father) is an error in interpretation of the facts. A 
syphilitic father can transmit virulent syphilis to his child only 
through intermediate infection of the mother; but on the other 
hand, without syphilizing the mother he can transmit to his off- 
spring, like an alcoholic or tuberculous father, both physical and 
psychic disturbances of development and a tendency to malfor- 
mations; this heredo-dystrophy mayor may not be associated with 
congenital syphilis of the child. 

Congenital syphilis differs from acquired syphilis in a funda- 
mental factor: the infection, of placental origin, takes place by the 
hematogenous route and is visceral from the start. The primary 
stage is accordingly absent in hereditary syphilis; there is no 
chancre; moreover, the secondary symptoms and the visceral 
manifestations of tertiary character are intermingled instead of 
successive. The course is therefore much less regular. 

In addition, the specific manifestations may become associated 
with dystrophic disturbances, malformations and various patho- 
logical tendencies, due to poisoning of the germinal tissue, sperma- 
tozoa and ova, as well as infection of the entire maternal organism, 
so that it is readily understood that the clinical picture of congenital 
syphilis may be rather polymorphous. 

[The offspring of a woman in the early stages of syphilis is always 
syphilitic; in the later stages the child may or may not be syphilitic. 
In a series of pregnancies the first products of gestation may be 
abortions or dead children, then children born alive and syphilitic, 



SYPHILIS 625 

then a series of apparently healthy children. Some of these appar- 
ently healthy children will really be free from syphilis and some 
may develop signs of syphilis within a few years; or possibly the 
first lesion will appear only after the lapse of many years. Some- 
times among the later children of a series, healthy and syphilitic 
children alternate. 

The explanation of these phenomena is simple but not generally 
understood. The blood of the syphilitic mother in the first year or 
two after infection is loaded with spirochetes some of which are 
sure to enter the uterine arteries and infect the fetus, producing 
there the active lesions of syphilis. In the tertiary stage of the 
mother's syphilis the spirochetes have become fixed in her tissues 
and her blood-stream only occasionally contains a few spirochetes. 
Under these conditions it is a matter of chance whether or not the 
spirochetes will reach the placenta and thus infect the fetus. But 
the blood of the fetus shares the quality of its mother's blood; in 
late syphilis, the fetal blood is ab ovo the blood of a tertiary syph- 
ilitic and contains the same substances which have given to the 
mother that kind of immunity which Neisser called anergy. It is 
this condition which renders her immune to a fresh infection though 
it offers no protection against local tertiary lesions. The spirochetes 
of a tertiary syphilitic mother that happen to penetrate to the fetus 
find conditions there like those in the mother. They produce no 
acute syphilis but becoming localized in the tissues develop the late 
lesions of syphilis hereditaria tarda.] 

The cutaneous and mucous manifestations alone are to be con- 
sidered in this book; the other symptoms will accordingly receive 
merely a brief mention. 

A classical distinction is made between early and delayed mani- 
festations of congenital syphilis. 

Precocious congenital syphilis sometimes manifests itself at birth 
by a peculiar fades: the skin is lifeless, wrinkled, flaccid, withered, 
like that of a very old man; the skull is deformed, with an abnor- 
mally high forehead ("olympian brow"), a natiform cranium, 
hydrocephalus, dilatation of the cranial veins and general athrepsia 
(Fig. 182). 

At birth, children with congenital syphilis may present three 
symptoms: syphilitic pemphigus; very frequently, an irritative 
serous, later purulent, coryza, drying in greenish crusts and inter- 
fering with respiration and nursing; mucous patches, situated espe- 
cially on the lips, often at the commissures, either fissured or 
radiating, rose-colored or opaline, oozing, crusted, sometimes with 
an indurated base and painful; they are a common cause of infec- 
tion of wet-nurses. 

Very soon, in the first weeks of life and usually before the fourth 
40 



626 1SFECTI0US DERMATOSES due to protozoa 

month, the cutaneous syphilides make their appearance. These 
have been especially well studied by Jacquet. 

Polymorphous erythemato-papular syphilides consist of more or 
less rounded salmon-colored or dark-red erythematous spots, situated 
on the buttocks, on the lower limbs, on the neck, around the mouth 
or in the folds. Some fade and disappear while others increase in 
size and become scaly, or thicken into papular discs; the elevation 
is often marked at the borders (cirdnate erythemato-papular syphilide I 
and sometimes at the center of the spots (extended papulo-lenticular 
syphilide). A well-marked "collarette of Biett" (p. 142) may be 
observed at their circumference. 

Jacqnet has pointed out that the palmar and plantar syphilides, 
known as syphilitic pemphigus, are of the same type and become 
bullous only in consequence of local factors. 




Fig. 182.— Early congenital syphilis; child of three months. Note the hydro- 
cephalus, the dilatation of the cranial veins, the papulo-erosive syphilides of the 
buttocks, loins, thighs, etc., the large abdomen and the puny limbs. 

The erythemato-papular syphilides may become erosive through 
maceration, or crusted and impetiginous, or sometimes ulcerative 
at points exposed to pressure or irritated by fecal matter; or, rarely, 
very scaly and psoriatiform. Furthermore, an acneiform syphilide 
has been described, formed by small umbilicated papules, centered 
by a small crust and agglomerated in patches. 

These polymorphous erythemato-papular syphilides are often very 
difficult to distinguish from the gluteal erythema of the newborn 
(p. 31). They are the substitute in congenital syphilis of the 
roseola and the various papular syphilides of adults; as a rule they 
are associated with mucous patches and sometimes with lesions of 
the nails and alopecia. Gummas are rare. 

Proper treatment of newborn infants having congenital syphilis 
saves the lives of the majority [without proper treatment very 
few of them survive even a year]. These children must never be 
entrusted to a healthy wet-nurse, but must be nursed by their own 
mother. In order to protect their digestive functions, mercurial 



SYPHILIS 



627 



medication by the mouth with van Swieten's fluid, etc., is prefer- 
ably replaced by mercurial inunctions (1 or 2 grams of mercurial 
ointment daily). It is advantageous to administer injections of 
novarsenobenzol in watery solution (5 mg. as the maximum dose 
per kilogram of body weight per week) into a scalp vein or in oily 
suspension into the buttock. 




Fig. 183. — Congenital syphilis. Circinate tuberculo-squamous syphilide on the thigh 
of a girl aged eleven years. 



Syphilis congenita tarda is the form observed in older children, 
in adults or even in old persons. For this chapter of pathology we 
are almost entirely indebted to the contributions of my teacher, 
A. Fournier, prior to whom the remote evidences of congenital 
syphilis were generally referred to scrofulo-tuberculosis, rickets, etc. 
It has been claimed that these patients must have had early mani- 
festations and that it is only the diagnosis that is delayed in such 
cases. This is probable but not certain. The didactic and practical 
importance of the subject is nevertheless considerable. 

The remote symptoms of congenital syphilis are in part specific 
and in part dystrophic in character. 



628 



ISEECTIOVS DERMATOSES DUE TO I'h'OTOZOA 



Decidedly specific are those which plainly present the features of 
tertiarism (Fig. 183); these require therefore no special description. 
Aside from the external integument, they affect chiefly the velum 
of the palate, the pharynx, the tongue, the nasal fossa? and the 
genital organs and are as a rule essentially ulcerative and destructive. 

Under the name of stigmata of congenital syphilis, a series of 
malformations, developmental disturbances and lesions have been 
grouped, whose characters point to syphilis in the parents on simple 
examination of the patient. Some are of a dystrophic character, 
while others are residues of specific lesions; efforts are now under 
wax to separate these two groups of symptoms. 

The principal signs are the following: Hutchinson's triad, namely 
dental malformations (Fig. 184), ocular lesions and auditory dis- 
turbances; bony deformities such as cranial and nasal malforma- 
tions, "sabre-blade" tibia and exostoses; testicular atrophy; infan- 
tilism; gluteal cicatrices of Parrot and radiating cicatrices of the 
lips. 




Fig. 184. — Congenital syphilis. Hutchinson's teeth 



Pathological Anatomy. — Before the discovery of the spirochete, 
the syphilitic lesions had already been recognized as possessing the 
features of an infectious inflammation; this affects in the first place 
the arterial and venous bloodvessels, altering the vascular walls and 
giving rise around them to the production of cellular infiltrations 
composed for the most part of plasmocytes. 

The more or less circumscribed or diffuse newformations which 
make up these infiltrations are capable of resolution in the primary 
or secondary stage of the disease, in the sense that they may undergo 
retrogression and practically complete absorption; the tertiary 
new formations, on the contrary, are incapable of resolution and 
tend lo form sclerotic tissue, provided they do not undergo necro- 
biosis; this may occur early, while the pathological tissue still has 
an embryonic structure, or later, after the sclerosis has become 
established. 'The name of giumnous degeneration is employed to 
designate this necrotic process in either case. 



SYPHILIS 629 

In .syphilitic chancre, the cellular infiltration of the cutis is very 
dense; the connective-tissue bundles are swollen, the walls of the 
bloodvessels are greatly inflamed, the epidermis is thickened at the 
borders, but has lost a number of its layers at the center, the remain- 
der being infiltrated with leukocytes and fibrine as well as degener- 
ated; in many cases, thinned and elongated interpapillary buds 
are its only residue. The treponema flourishes, especially in the 
vascular walls, whence they seem to emigrate in part into the 
vascular lumen, which is very important in view of the generali- 
zation of the infection; in part, into the connective-tissue bundles 
and spaces, whence the lymphatics carry them into the glands; 
and finally in the epidermis, where they may be transmitted by 
contagion. 

The lenticular papule may serve as the model of a secondary 
syphiloma (Fig. 31). The infiltration of plasma cells interspersed 
with a few giant cells is arranged in more or less continuous 
perivascular cuffs. The epidermis is merely stretched; or it may 
be parakeratotic, or edematous and infiltrated with leukocytes, or 
degenerated, resulting in the formation of scales, crusts, erosions or 
ulcerations. 

In the roseola the cellular infiltration is very slight. It is some- 
what more considerable in the mucous patches, which may have the 
structure of papules, with an opaline epithelium through separation 
of the cells and very abundant immigration of white corpuscles. 
These lesions are literally teeming with spirochetes. 

The tertiary lesions differ from the preceding in their course 
rather than in their characters; the treponema, however, has only 
very rarely been demonstrated. 

Genuine syphilitic gumma seems to originate through thrombo- 
phlebitis in the vascular plexus of the hypoderm; the profuse 
cellular newformation of which it consists undergoes liquefaction 
while at the same time the stroma becomes necrotic. 

In syphilitic tubercle, the newformation, in which the bloodvessels 
and lymphatics are greatly dilated, is partitioned by sclerotic strands. 
As compared with the papule, it is therefore more fibrous, hence its 
hardness; contains more venous blood, hence its dark color; and 
the sclerosis persists after its disappearance, hence the cicatrix 
which it leaves behind (Fig. 87). The epidermis may be hyper- 
trophied in the proliferative varieties; or it may be edematous, 
degenerated and infiltrated with leukocytes in the tuberculo-crusted 
and tuberculo-ulcerative forms. The crust, which characterizes 
the last two forms as well as the secondary ulcerative sjphilides of the 
precocious malignant form, develops at the expense of the epidermis 
and the infiltrated necrotic upper layer of the cutis; it accordingly 
precedes the ulceration. Endarteritis and phlebitis are regularly 



030 INFECTIOUS DERMATOSES DUE TO PROTOZOA 

found around all tertiary syphilomas. All these forms may present 
a tuberculoid structure (Nicolas and Favre). 

The lesions of congenital syphilis do not markedly differ from 
those of acquired syphilis. The abundance of spirochetes in its early 
manifestations has already been referred to. 

Diagnosis. — The diagnosis of syphilis should always be guarded; 
I repeat that the patient should be very cautiously informed of its 
existence. 

Sometimes the diagnosis is obvious from the start, while in other 
cases, numerous and painstaking investigations are required. It 
may happen that in spite of these investigations no definite con- 
clusion is possible. Even in countries supplied with well-informed 
physicians, a considerable number of previously undiscovered cases 
of syphilis are met with and this number has grown since our 
knowledge of the specific origin of the so-called parasyphilitic 
diseases and since the common employment of the Wassermann 
reaction. 

In connection with every type of syphilitic symptoms, I have 
indicated its diagnostic features, based on its objective character- 
istics. Some of these are indicative, notably the typical hard 
chancre, roseola, lenticular papular eruption, arciform syphilides, 
alopecia areolata, pigmentary syphilide of the neck, circinate 
tertiary syphilides, etc. 

When it is not possible to affirm the existence of syphilis from 
the morphological aspect of a given lesion, as is true in by far the 
majority of cases, there is a series of indirect measures at our com- 
mand that enable us to arrive at a certainty; these are of unequal 
intrinsic value and not indiscriminately applicable in all stages of the 
disease; nor is it always possible or necessary to employ them all. 

Among these procedures, some are of a clinical nature and furnish 
only more or less probable data. 

They are based upon: (1) the presence of concomitant lesions; 
certain associations are almost pathognomonic; I have emphasized 
the value of progressive general glandular enlargement; (2) the 
regular succession and sequence of the lesions; and (3) on the 
history of exposure to contagion and the examination of the con- 
taminating party (Bassereau). The ex-juvantibus method [test by 
treatment] has too many serious disadvantages to justify its 
employment. 

Recent discoveries have enriched these traditional diagnostic 
principles by the introduction of new scientific procedures belonging 
to the domain of the laboratory. 

The demonstration of the spirochete, in stained smears or by 
direct ultra-microscopical examination of the serous discharge, 
constitutes the method of choice in case of oozing lesions of the 



SYPHILIS 631 

first stages, namely a chancre or mucous patches; a positive result 
is absolute proof. However, this demonstration fails in the ulcer- 
ative lesions, even of the secondary period; it is very complicated 
in non-ulcerative syphilides and negative tests, even when repeated, 
possess no value. In the case of tertiary syphilides, this method is 
of no assistance at all. 

The demonstration of the spirochetes in biopsy-sections requires 
more time and a more elaborate technic; its value is open to the 
same objections as those of the direct procedure. It is applicable to 
the non-ulcerative lesions of the most virulent stage of the disease. 

The method of demonstrating the virulence of a lesion by inocula- 
tion into monkeys, as formulated by Thibierge and Ravaut, or by 
inoculation of the rabbit's cornea or scrotum, is absolutely con- 
clusive when the outcome is positive. But its inherent difficulties 
and the delay prevent its employment as a customary procedure. 

The sero-diagnostic method of Wassermann-Bruck-Neisser, based 
on the complement-fixation method of Bordet-Gengou, depends, 
not upon the demonstration of the noxious agent, but upon the 
demonstration of the resulting humoral changes. Its technic is 
extremely delicate; it necessitates minute precautions with con- 
trols and a correct interpretation of the findings. 

The fact is now known that the Wassermann reaction is not 
strictly specific, for a positive reaction is yielded by yaws, trypanoso- 
miases and leprosy. In a general way, however, under ordinary 
conditions and with a reliable worker, a positive outcome may be 
credited with absolute value and a series of negative results with a 
value of great probability. 

Sero-diagnosis is not applicable in the initial stage of the chancre, 
because the reaction does not appear until about three weeks after 
the onset of the primary lesion. It is a valuable aid in the secondary 
stage and especially in the tertiary stage. It is well to keep in 
mind, however, that the only information supplied is to the effect 
that the individual is syphilitic, without justifying a statement that 
a given doubtful lesion presented by this individual is itself of 
syphilitic nature. The Wassermann reaction is most serviceable 
in the latent stages of the disease, the other methods, except the 
luetin test which will be discussed presently, being inapplicable at 
these times. It may also be utilized to a certain extent in the 
direction of the treatment. 

Milian and others have studied under the name of reactivation 
the reappearance of a positive Wassermann reaction under the 
influence of treatment with arsenicals; it is claimed to occur early 
(from the fifth to eleventh day) in the secondary stage, but is transi- 
tory; rather delayed (toward the fifteenth day) and generally 
prolonged in the tertiary stage. [In my opinion the "provocative" 



632 INFECTIOUS DERMATOSES DUE TO PROTOZOA 

Wassermann test is not only useless but is apt to be misleading. 
Cf. Am. Journ. Syphilis, April, 1919.] 

For the cutaneous reaction to luetin, credit is due to Noguchi 
(1912). Luetin is a sterilized emulsion of a culture of six strains of 
Spirochete pallida; it is employed in intradermic injections. The 
results yielded by it are not always very reliable. A positive 
reaction manifests itself after twenty-four to forty-eight hours, by 
the appearance of a papular or pustular elevation which lasts a week 
or longer; sometimes it is sluggish or delayed. 

A negative reaction is erythematous or faintly papular and sub- 
sides by the fifth day. It is claimed that the percentage of positive 
results is only 33 in the primary stage and 47 in the secondary stage, 
but from 80 to 90 in tertiary syphilis, whether latent or congenital; 
so that there is no conformity with the Wassermann reaction. A 
certain number of non-syphilitic persons react likewise. An analo- 
gous reaction to that of luetin, which is on the whole only a manifes- 
tation of allergy has been obtained on the other hand with extracts 
of syphilitic organs and even with other substances. The value of 
the luetin-reaction is still a matter of controversy. [That the 
reaction is not specific is shown by the fact that it may occur after 
an injection of agar (Stokes) and possibly other substances; more- 
over a reaction is regularly obtained in non-syphilitics who have 
ingested iodides as long as a month before.] 

The histological diagnosis of syphilis through examination by 
biopsy has been relegated to a secondary rank; under certain con- 
ditions and especially in combination with sero-diagnosis, this 
method may prove serviceable. 

It will be readily understood that the various procedures outlined 
above may be combined in several ways according to the supposed 
stage of the disease. 

Treatment.— Syphilis is one of the diseases against which we are in 
a good state of preparedness. 

Lacking a preventive or curative serum, which remains to be dis- 
covered, we possess mercury which often does wonders when it is 
properly employed and well tolerated; and there are furthermore 
the recently introduced arsenical compounds, which are still more 
powerful; a few medicinal adjuvants and hygienic prescriptions 
complete our therapeutic armamentarium. 

Mercury. — It is not known if mercury acts directly as a parasiti- 
cide, or through the intermediation of antibodies, or by increasing 
the defensive reactions of the organism, etc. A few r days of treat- 
ment suffice to render the demonstration of spirochetes in the syphi- 
litic lesions impossible. At any rate, mercury not only cures the 
symptoms but also prevents relapses and tertiarism and even 
hereditary transmission. Like main' others, I have been able to 



SYPHILIS 633 

note that the vast majority of syphilitics who were treated with 
mercury alone for a long time and with good doses remained definitely 
free and acquired a permanently negative sero-reaction. 

The mode of introduction of the medicinal agent is not of capital 
importance in itself, the essential factor being the amount which has 
really been absorbed. The reason why the old mercurial fumi- 
gations have been abandoned and the obstacle to the adoption of the 
inhalation method, through the mercurial flannels of Merget or 
through the powder- or ointment-bags of Welander, which the 
patient must wear on his person night and day, consist in the 
uncertainty as to the dosage absorbed under these methods of 
administration. 

Mercurial inunctions are open to the same criticism; furthermore, 
they are dirty and suggestive. They enjoy great popular favor, 
however, especially abroad; for children of tender years, they con- 
stitute the procedure of choice. [A 30 per cent, calomel ointment 
seems to be not less efficient, and has the avantage of cleanliness.] 

The full-strength or 50 per cent, mercurial ointment is employed 
for these inunctions, in daily doses of 6 or 7 grams for a man, 5 
grams for a woman, 1 or 2 grams for a newborn child. The inunc- 
tions must be applied for a long time, during ten to fifteen minutes, 
until there is apparent penetration; the regions should be carefully 
alternated, rubbing on the first two days one of the sides of the 
thorax, on the following days the internal aspect of one of the limbs, 
after which the series is resumed, avoiding the axillse, the groins 
and the scrotum, which are too much exposed to hydrargyria. The 
treated part is covered with gauze for the night; on the following 
morning it is carefully cleansed with soap and dusted with powder. 
[Since mercury is slowly vaporized at the body temperature a part 
of the effect of inunctions is due to respiratory absorption. Inunc- 
tions are therefore most effective when made in a small room with 
closed windows.] 

The buccal route, for a long time the most generally used, also 
has its disadvantages: uncertainty as to the actual penetration of 
the dose into the tissue-juices, low effectiveness and lasting digestive 
disturbances; the latter attract little attention on acount of their 
delayed appearance, but occur almost infallibly in patients who have 
been treated for a long time. 

Use is made either of van Swieten's fluid, 4 to 6 teaspoonfuls 
daily in a little milk, or Dupuytren's pills (bichloride of mercury and 
extract of opium aa 00.1, excipient and glycerine q. s. for 1 soft pill) 
or especially Ricord's pills (protoiodide of mercury 0.05, extract of 
opium 0.01, excipient and glycerine q. s.) to be taken at meals, in 
a dose of 2 pills daily for an adult, 1| for a woman. 

The rectal route may be utilized. Audry recommended supposi- 



634 INFECTIOUS DERMATOSES DUE TO PROTOZOA 

tories of cacao butter with an addition of 40 per cent, gray oil, in 
such a proportion as to contain 0.02 to 0.04 of metallic mercury; 
this method is slow in its action. 

Mercurial injections are at present one of the fundamental methods 
of treatment of syphilis. They insure a strict dosage, exclude fraud 
or negligence on the part of the patient, spare the digestive apparatus 
and when properly applied and well tolerated are found to be almost 
as rapidly effective as arsenical medication. At the present writing, 
I regard mercurial injections as an indispensable complement of 
treatment with the arsenobenzols. Further on I shall point out 
how the two medications may be combined. 

Mercurial injections are made in the region of the buttocks. 
The pain of the puncture is practically zero, abscesses are no longer 
to be feared, pain coming on after the injection is insignificant 
provided the technic is correct and nodosities are rare and usually 
painless. On the whole, the drawbacks of the method cannot be 
compared with its advantages. 

The technic is now definitely established and the following rules 
must be observed: The necessary implements are a needle from 
6 to 7 cm. long, preferably of iridium-platinum and an accurately 
divided sterilizable syringe made entirely of glass; the whole outfit 
is first to be boiled. The puncture-points are selected as follows: 
(1) On a horizontal line passing three or four fingers' width below 
the iliac crest; (2) on a vertical line passing two fingers' width from 
the intergluteal fold. It is advisable to begin with the left buttock 
and to inject on the two sides alternately, of course avoiding the 
previously punctured points. The patient lies on the abdomen, with 
complete muscular relaxation; the area selected is cleaned with a 
cotton wipe soaked in benzine, ether or alcohol. The needle is 
plunged in vertically with a clean thrust and a minute is allowed to 
pass, in order to be sure that no drop of blood flows through its 
lumen; should this happen, the needle will have to be [partlyl 
withdrawn and inserted elsewhere, to guard against embolism; 
otherwise, the syringe containing the desired dose is adjusted [and 
the fluid slowly injected]; at the end of the procedure, a drop of 
collodion or a piece of plaster is placed over the puncture-orifice. 

Mercurial injections are administered with insoluble compounds 
or with soluble salts. 

The former have the advantage of being applicable at longer 
intervals, usually once a week. The soluble injections must be 
repeated every day, causing a loss of time and much inconvenience 
outside of hospital practice; they have a powerful and rapid, but 
less durable effect. 

Gray oil is the most practical insoluble injection. The formula 
of the Codex for 1908 contains: purified mercury, 40 grams; lano- 



SYPHILIS 635 

line, 26 grams; vaseline oil, 60 grams; 1 c.c. contains 0.4 gm. of 
mercury. This preparation is employed luke-warm, using a syringe 
of narrow caliber [tuberculin syringe]; 0.07 to 0.12 Hg weekly 
should be injected into a man and 0.06 to 0.10 into a woman. 

Calomel injections are much more energetic and efficient; their 
action is nearly as rapid as that of arsenobenzol. They are often 
alone sufficient to cure certain lesions, such as the obstinate palmar 
syphilides and the tertiary lesions of the tongue. The dose to be 
injected is from 0.05 to 0.10 (or 1 c.c. of the formula: calomel (by 
vaporization) 0.5 or 1.0, vaselin and vaselin oil, aa 5 grams). 
Their drawback consists in the sometimes severe but as a rule quite 
tolerable pain caused by them. This is largely obviated, as I have 
suggested, by adding per 1 c.c, 0.03 of guaiacol and 0.02 of cam- 
phor. The same addition is advantageously made to gray oil and 
to the other insoluble injections. 

The basic salicylate of mercury (0.10 per injection), or yellow 
oxide (0.05 to 0.10) may be substituted for gray oil, without, how- 
ever, being preferable to it. 

[With all the mercurial suspensions in oil, it would seem physio- 
logically preferable to use olein (ol. olivarum) rather than foreign 
bodies like the paraffins (vaseline, vaseline oil, etc.). Furthermore, 
the larger the volume of the injected mass the greater the pain. I 
employ calomel in 20 per cent, suspension and the salicylate in 33 
per cent, suspension, injecting a proportionately smaller amount 
of fluid.] 

Soluble injections are made with benzoate of mercury according 
to the formula of Gaucher; with bibromide or biniodide of mercury, 
or with the cyanide. The daily dose is from 0.01 to 0.03 of each of 
these salts; the pain is generally moderate. Bichloride of mercury 
is more painful and should be rejected for this reason. Tolerance 
varies greatly according to the patients and it is advisable to look 
in each particular case for the most readily tolerated formula. 
Various preparations of mercury disguised under proprietary names 
(hermophenyl, enesol, etc.), are not sufficiently reliable in their 
action. 

Intravenous injections of soluble salts may also be recommended ; 
the cyanide of mercury alone is used for the same [the bichloride 
is also employed]. They are entirely painless and very promptly 
efficient. [They are administered in normal saline solution.] 

Local mercurial treatment of syphilides, especially the tertiary 
manifestations, is entirely reasonable; it serves as an adjuvant of the 
general medicinal treatment and prior to the era of arsenobenzol 
injections was recommended by me in those cases where the patient's 
buccal or intestinal condition prevented an energetic general mer- 
curialization. I have been well pleased, especially in the treatment of 



636 INFECTIOUS DERMATOSES DUE TO PROTOZOA 

circumscribed leukoplakias and leukoplasic ulcer, with local injec- 
tions of a few drops of an isotonic cyanide solution of 1 to 3000 
(formula: cyanide of mercury, 0.3.'!; cocain chlorhydrate, .">.(); 
sodium chloride, 7.0; sterilized water, 1 liter) repeated twice weekly. 
The traditional mercurial plaster, salves and mercurial baths are no 
longer indicated at the present time. 

Mercurial complications, hydrargyria are possible with all com- 
pounds, all formulas and all methods without exception. Their 
possible occurrence renders it necessary first to test the patient's 
sensibility and always to proceed with caution. 

Mercurial stomatitis was a distressing and formidable symptom 
in the days when salivation was systematically aimed at. The 
present tendency is to consider it as due to the fuso-spirillary asso- 
ciation and induced by the irritation of the mouth. Its development 
may be prevented by putting the mouth in good condition before 
beginning the treatment and by maintaining great cleanliness. 
The use of tobacco must be interdicted. The gastro-intestinal 
apparatus likewise requires continuous supervision. Finally, the 
urine must be watched. 

Arsenic. — Arsenic in all its forms had long been advocated as an 
adjuvant of mercurial treatment; sodium arsenate, the cacodylates, 
methylarsenate, hectargyrium and other preparations have served 
for this purpose. 

Since a dozen years, however, a direct specific medication has been 
sought in new arsenical compounds. Atoxyl and arsacetine were 
promptly abandoned as too dangerous. The " hectine" of Mouneyrat 
has enjoyed a certain popularity, but this product does not seem 
to me to be better than a good adjuvant. 

In the course of his investigations on the arsenic treatment of the 
spirilloses, Ehrlich in 1909 stopped at a compound, the dichlor- 
hydrate of dioxydiamido-arsenobenzol, w r hich was numbered 606; 
this product was labelled with the name of salvarsan; at the present 
writing it is manufactured everywhere and known as arsenobenzol. 
[In the United States the official name since 1917 is arsphenamine.) 
Shortly afterward he recommended a related product, much more 
convenient to employ, the dioxydiamido-arsenobenzol-monomethy- 
lene-sulfoxylate of sodium, or 914, or neosalvarsan, which is cus- 
tomarily designated by the name of novarsenobenzol for neo- 
arsphenamine]. Other more or less analogous arsenical salts, notably 
galyl, luargol, etc., have been produced and tried in France; these 
investigations are still under way. 

Briefly, arsenobenzol and novarsenobenzol constitute the anti- 
syphilitic arsenical medication of the present day. 1 

1 Wherever treatment with arsenobenzol, or the arsenobenzols, has been referred 
to in the course of this hook, I have meant intravenous injections with arsenobenzol 
or witli novarsenobenzol [arsphenamine or neo-arsphenamine]. 



SYPHILIS 637 

The hope which had been aroused of a "therapia sterilisans 
magna," a radical and rapid cure of syphilis has not been realized; 
it must be abandoned and doses employed which do not expose to 
the gravest risks. Nevertheless, the efficacy of arsenobenzol and 
almost to the same degree of novarsenobenzol is not less remarkable; 
in a few days they will cicatrize a chancre, obliterate roseola or 
mucous patches; when employed in the primary stage and especially 
in combination with mercurial injections, they almost certainly 
protect against all secondary manifestations and usually maintain a 
permanently negative Wassermann reaction. The test of time is 
not yet sufficient to state that patients treated in this way will 
remain free from tertiary and parasyphilitic lesions. While this 
may be hoped for, it is advisable to complete the treatment with 
mercury for the present. At any rate, the dangers of contagion are 
immeasurably diminished in these "silenced" cases of syphilis and it 
is needless to dwell upon the social importance of this result. 

The manipulation of the new arsenical compounds is difficult; 
their employment cannot be said to be absolutely devoid of danger; 
especially in the early days, serious and even fatal results have been 
noted. Better regulated doses and extreme precautions, however, 
have reduced the risks of this treatment to a minimum. 

There is a practically general agreement as to their administra- 
tion only by the venous route. Those who have witnessed the intol- 
erable pains and fearful sloughs which were often produced by 
intramuscular injections of 606, such as were originally administered, 
have abandoned them altogether. Balzer and Dumouthiers advo- 
cated intramuscular injections of novarsenobenzol in doses of 
0.25, twice daily. These are often not particularly painful, have a 
slower action and are only rarely indicated. Nowadays, every 
physician should be familiar with the technique of intravenous 
injections. 

Arsenobenzol is the most active and the most permanently steriliz- 
ing antisyphilitic remedy known. Its watery solution is acid and 
must be neutralized or rendered slightly alkaline by the addition of 
a sodic hydrate solution, then diluted with physiological salt solu- 
tion of 7 per 1000, prepared with pure sodium chloride dissolved in 
freshly distilled water; the total amount to be injected is according 
to some writers from 150 to 200 c.c, according to others 50 c.c. for 
each 0.10 of the remedy. 

Nov-arsenobenzol is generally preferred on account of the relatively 
simple instrumentation and mode of preparation of the solution, 
especially when the very convenient procedure of intravenous injec- 
tions in concentrated solution of Ravaut is adopted and carried out 
as follows: Immediately before it is to be used the contents of a 
nov-arsenobenzol ampoule is dissolved in 5 to 10 c.c. of physiological 



38 INFECTIOUS DERMATOSES DUE TO PROTOZOA 

salt solution, 4 per 1000, or the same quantity of distilled water or 
even freshly boiled and cooled water may be employed. Solution 
is instantaneous; the solution is drawn into an all-glass sterilized 
syringe, provided with a short-bevelled platinum needle; the patient 
lies down and the arm is put on the stretch ; the needle is now inserted 
into a vein at the bend of the elbow which has been made prominent 
by applying a rubber band on the arm; when the blood flows back 
into the syringe indicating that the needle is properly inserted, the 
band is removed from the arm and the piston is gently pushed in; 
after the injection has been made and the needle is withdrawn, no 
dressing is required. [The field of operation must, of course, have 
been sterilized with alcohol or a weak solution of iodine.] 

Some precautions are needed with all arsenical compounds. In 
case of virulent syphilis, with multiple manifestations, it is advisable 
to treat the patient for two or three days before the arsenical injec- 
tion, with injections of a soluble mercury salt; this guards against 
an attack of fever with malaise, known under the name of Herx- 
heimer's reaction and attributed to the sudden absorption of the 
products resulting from a large number of disintegrated spirochetes. 
The patient must fast three hours before and five hours after the 
injection. Examination of the urine just before the injection is 
indispensable, so as to permit a diminution of the dose or its post- 
ponement to a later date, in case albumin is present. The ampoule 
must be carefully examined to see that its contents consist of a 
light yellow powder, unaltered by penetration of air. 

As a rule no reaction of any kind follows. It is advisable, however, 
to warn the patient of the possible onset of certain symptoms, such 
as headache, mild diarrhea, a chill with a slight ephemeral fever, 
general prostration, nausea, sometimes vomiting, rarely an erythe- 
matous eruption; he will be so much the more pleased should these 
symptoms fail to make their appearance. 

Threatening, grave and even fatal complications, the mechanism 
of which has been extensively discussed, have been observed espe- 
cially with arsenobenzol, more particularly at the time of the first 
ventures; they have become extremely rare since the doses are more 
carefully regulated [the quality of the arsphenamine improved and 
more attention paid to the preparation of the patient]. A purplish 
swelling of the face, in the course of an over-rapid injection, known 
as "nitritoid crisis," may be efficiently controlled, as shown by 
Milian, through injections of | mg. of adrenalin, which exerts a 
a preventive effect. In case the injection be followed in the next 
few hours or the first days by convulsions or delirium or spasms 
with a tendency to coma, a profuse venesection should at once be 
preformed, adrenalin should be injected, a spinal puncture made 
and intravenous irrigations with physiological salt solution be 



SYPHILIS 639 

administered. The employment of these measures has proved suc- 
cessful in very alarming cases, which, let me repeat, are of altogether 
exceptional occurrence. 

Auxiliary Medication. — Potassium iodide, introduced into the 
treatment of syphilis by Wallace and by Ricord, for a long time 
advocated as a specific in tertiary lesions, has lost much of the favor 
it formerly enjoyed, especially since the introduction of arseno- 
benzol and since it has been shown to have no influence on the 
Wassermann reaction. It may be described as not indispensable. 
In the secondary stage, in daily doses of 1 to 3 grams, it serves to 
control the headache and the painful manifestations. In the ter- 
tiary stage, it is used, combined with mercury in doses of 4 to 12 
grams, to stimulate the healing of sluggish lesions and against the 
lesions of the nervous system or the viscera. Its employment should 
be avoided, however, in the treatment of so-called parasyphilitic 
disorders (general paralysis, tabes, etc.) and in the case of laryngeal 
symptoms. In subcutaneous injections it is too painful, but it may 
be administered in enemas [and has been given intravenously; but 
this seems to me a futile procedure]. Other iodide compounds 
besides potassium iodide are of less efficiency. 

Some authors prescribe as a routine procedure a mixed iodo- 
mercurial syrup, of the type of Gibert's syrup; it is better to admin- 
ister the two medicinal agents separately, Sulphur medication, 
cod-liver oil, rarely iron, more frequently hydrotherapy, cures at 
watering-places with warm mineral springs, such as Luchon, Uriage, 
la Bourboule, Amelie-les-Bains [or Hot Springs], or sodium chloride 
springs, may prove of the greatest value for the improvement of 
the patient's general condition or his tolerance of mercurialization. 

It is always necessary to watch the alimentary, physical, occupa- 
tional and emotional hygiene of syphilitic patients, cutting out 
especially the abuse of alcohol, venereal excesses, late hours, and 
overstrain of all kinds. A moderate use of tobacco may be permitted, 
except at times where the production of buccal mucous patches is 
threatened or when it seems to favor the onset of mercurial stomatitis. 

General Conduct of the Treatment. — The so-called abortive treat- 
ment of MetchnikofT consists of rubbing without delay a calomel 
salve, 1 to 3, into the mucous membrane or an erosion which has 
been exposed to syphilitic contact. Although it has been experi- 
mentally tested in monkeys, this procedure is not free from dis- 
advantages and has not been demonstrated to be superior to simple 
washing with soap and water. [Prophylactic treatment after 
venereal exposure is obligatory in the United States army. An 
experience based on several hundred thousand cases shows that the 
MetchnikofT inunctions applied within six hours after exposure are 
a practically certain preventive of infection.] 



640 INFECTIOUS DERMATOSES DUE TO PROTOZOA 

Early excision of the chancre is certainly not capable, as had been 
believed, of bringing about an eradication of syphilis; when the 
operation is possible without producing deformities, some authors 
have found it useful, but there is nothing to show that it modifies 
the gravity of the infection. 

A fundamental rule, which must never be slighted, is as follows: 
Never begin specific treatment before the diagnosis has been positively 
established: this would be a serious error, which before long would 
inevitably lead to insuperable difficulties. 

When the diagnosis is definitely established, the general specific 
treatment must at once be instituted, taking care at the same time 
of the local lesions and guarding against contagion. Recent experi- 
ence has shown the great importance of a vigorous offensive, striking 
hard and strong, at least in the primary stage. In all stages of the 
disease, we must aim not only at extinguishing the actual manifes- 
tations, at "bleaching the syphilitic" to use a French expression, 
but at completely stamping out the virulence of the disease and 
safeguarding the future — aims which are usually attainable. 

The problems dealing with the general conduct of the treatment 
have been reawakened by the introduction of the arsenical medica- 
tion. The era of trials and discussions is not yet past, so that no 
detailed and definite rules can be formulated. 1 shall therefore 
restrict myself to describing my actual mode of procedure and that 
of the majority of experienced syphilographers. 

It is quite generally agreed to begin in all cases with a medication 
which although cautious must be as energetic as the patient can 
tolerate; and to continue with the tried and approved method of 
chronic intermittent treatment. 

It seems to me highly advantageous to begin the treatment with 
novarsenobenzol or arsenobenzol. These remedies are positively 
indicated for patients likely to contaminate their environment, 
married persons, those expecting to be married, fathers of families, 
prostitutes, etc. ; or in the presence of malignant symptoms or lesions 
of a destructive character; or when a bad condition of the teeth, 
which is common, or of the intestinal tract suggests that mercury 
will be badly tolerated; or in tuberculous patients in whom the 
breaking down of tubercles is favored by mercury. Inversely, these 
remedies should be omitted or very cautiously employed in cases 
of cerebrospinal, meningeal, renal, cardiovascular or hemorrhagic 
manifestations; under these conditions, it is preferable to rely exclu- 
sively upon soluble mercurial injections. 

In a general way, in the absence of contra-indications, I consider 
it advisable to give at first about 5 or 6 injections of novarseno- 
benzol at a week's interval (not less than four and very exception- 
ally more than seven) in progressive doses (of 0.30; 0.45; 0.60; 



SYPHILIS 641 

0.75; 0.90); in case of arsenobenzol the doses are one-third smaller 
and it is better not to go above 0.50. In this increasing dosage, it 
is of course necessary to take into consideration the signs of possible 
intolerance, the strength of the patient, the character and more or 
less obstinate behavior of the symptoms. 

Next, after a few weeks of rest, mercurial treatment is begun with 
soluble injections in a series of 20 to 30 every two or three months; 
or, as seems preferable to me, with injections of gray oil, in strong 
doses, in series of 6 ; three of these series in the course of each of the 
first two years, another two or three series in the course of the third 
and again in the fourth year, appear to be a treatment capable of 
providing adequate security. 

The question has been raised why the two powerful antisyphilitic 
agents in our possession, arsenic and mercury, should not be simul- 
taneously employed from the start. As a matter of fact, this com- 
bined treatment — which consists in applying during the first series 
of novarsenobenzol injections, 4 or 5 soluble mercurial injections 
in the intervening days — is, as a rule, very readily tolerated by robust 
individuals, in spite of the theoretical fears which have been enter- 
tained; stomatitis and albuminuria are of rare occurrence. 

It is assuredly rational and advantageous, especially in the pres- 
ence of some special indication (positive Wassermann reaction) to 
interpolate in the course of the second to fourth year, one or 
two series of novarsenobenzol injections between the mercurial 
treatments. 

The same procedure, combined or alternating medication, may 
be adopted in the treatment of late secondary lesions or tertiary 
manifestations. 

One of the most mooted questions is that of the part played by 
the Wassermann reaction in the conduct of the treatment. Some 
allow themselves to be guided to a large extent by the modifications 
of the Wassermann reaction of the bloodserum, periodically tested 
every three months for instance. Some even go so far as to follow 
systematically the indications furnished by the reaction of the cere- 
brospinal fluid. Others go too far in the opposite direction and dis- 
claim all indicative value of these reactions for the treatment. In 
my opinion, this factor should be kept in mind, but to be guided 
by the serum-reaction alone would result either in abbreviated 
treatments when it remains negative, or to unduly prolonged or 
dangerously increased medications in case it remains positive. It 
is a matter of judgment and clinical sense. 

From a very elaborate review of this question, Hudelo, writing in 

Paris Medical, May 5, 1917, concludes that the following procedure 

is to be recommended : At the beginning, administer 8 or 9 injections 

of nov-arsenobenzol at five-day intervals until a total of 4 to 5 grams 

41 



642 INFECTIOUS DERMATOSES DUE TO PROTOZOA 

has been given, interpolating twenty injections of 0.01 of a soluble 
mercury salt. After six weeks to two months, if the Wassermanu 
test of the blood is negative, injections of soluble mercury salts are 
to be given for six months, 10 each month, or 20 every two months; 
if, on the contrary, the Wassermann reaction again becomes positive, 
repeat the combined treatment of the first forty days. At the end 
of the first period of six months, a spinal puncture is made; if it 
reveals an abnormal condition (hypertension, albuminosis, lympho- 
cytosis, positive Wassermann), the duration of the intervals of rest 
must be reduced or a prolonged combined treatment be resumed; 
when clinical symptoms are present (headache, etc.), the doses 
should be diminished, but the series be prolonged, as recommended 
by Ravaut. At the end of the sixth month, administer a series of 20 
soluble mercury injections, or of 6 injections of gray oil, every three 
months until the completion of the second year; every four months 
during the third; every six months in the fourth and in the fifth 
year. The Wassermann reaction should be verified about once in 
four months. 

In all probability, the new methods of specific treatment will 
permit an abbreviation of the time-honored delay of four or five 
years expected from syphilitics who are contemplating marriage. 
It is advisable, however, while taking into consideration the thor- 
oughness of the treatment and the serum-reaction, not to depart 
too far from the limits established by long experience; as heretofore, 
the recommendation of a course of treatment with gray oil shortly 
before marriage is sound advice. 

[As the author has well said, the period of trials and discussions has not 
yet passed. I need make no apology for entertaining very different views 
in regard to the administration of arsphenamine and I have little hesitation 
in presenting them even at the risk of some repetition because it is desirable 
that the reader become acquainted with other views. The final verdict on 
this subject belongs to the future. 

Principles of Treatment. — The fact is indisputable that many cases of 
syphilis have been cured by a single course of injections of arsphenamine 
or even by a single injection in the first weeks after infection. In the later 
stages it requires prolonged treatment with many courses to bring about 
a permanent Wassermann reaction. This difference probably depends 
on two factors: the spirochetes have become localized in regions where 
thejr are not readily reached by the arsphenamine or they have assumed a 
form in which they are resistant to the drug, an encysted or spore form. 

To meet the indications arising from the possibility of resistant forms we 
employ the interrupted method of sterilization, the method which long 
experience has shown to be the best with mercury as the laboratory has 
shown it to be the best and, depending on the medium, often the only pos- 
sible method of sterilization. Periods of treatment must alternate with 
periods of rest during which the organisms may emerge from their resistant 
stage in order that our sterilizing agents may again successfully attack them 
in their developed form. 



SYPHILIS 643 

To meet the indications derived from the possibility of remote or inacces- 
sible localization of spirochetes it is necessary to employ the drug in such 
dosage and to maintain the saturation of the blood with it for such periods 
that even the tissues least well supplied with a circulating fluid will receive 
an adequate amount of arsphenamine to kill the germs. 

We employ the soluble salts of mercury in daily doses because we aim 
at maintaining a fairly constant amount of mercury in the system during 
the period of treatment. We give the insoluble compounds of mercury in 
weekly doses because with their slower elimination we accomplish the 
same result with less frequent injections. In rapidity of elimination, 
arsphenamine is comparable to the soluble salts of mercury. At the end 
of twenty-four hours only a small fraction of the quantity injected remains 
in the system. To maintain a saturation of the system for a considerable 
period it would be necessary to administer arsphenamine in daily doses. 
This result, however, would not be advantageous even if it were technically 
feasible because arsphenamine, so far as we know, acts simply as a spiro- 
cheticide and a single injection of the drug kills all the spirochetes which 
it can reach in adequate dosage. There are no spirochetes left in the blood 
to be acted on by the arsphenamine administered within the next day or 
two; it is only after the lapse of a longer time that we can again expect to 
find free spirochetes in the blood. But the repetition of the dose at short 
intervals for a few days serves to maintain a degree of saturation of the 
system with the drug which makes it possible for the arsphenamine-laden 
fluids to reach remote and outlying regions in sufficient dosage. 

The principles on which my arsphenamine treatment of syphilis are 
based are therefore : 

1. The principles of interrupted sterilization to destroy the resistant 
forms. 

2. The principle of prolonged saturation to reach and destroy the remote 
or deeply hidden germs. 

Arsphenamine is now made in many chemical factories in different 
countries. The different products are by no means equally free from 
impurities which cause immediate or later reactions. Some of these products 
are followed by dangerous reactions in a large percentage of cases; some are 
far more free from these dangers even than was the original 606. The general 
practitioner must choose his arsphenamine in accordance with the experience 
of those specialists who have larger opportunities for acquaintance with 
the different brands. The question of cost or of convenience in preparation 
should have no weight in dealing with so potent a drug and so grave a 



Dosage, Preparation of Solution and of Patient. The dose should be 
proportioned to the weight of the patient, making some allowance for sex 
and a physical condition possibly weakened by disease, alcoholism, etc. 
A dose equal to 0.1 for each twenty-five pounds of body weight is the dose 
for a man; 0.1 to thirty pounds of weight for a woman or a child; and half 
that amount for an infant. With an otherwise healthy patient the first 
dose should not be less than the full dose. The employment of a small 
initial dose followed once a week by slightly larger doses is open to the grave 
objection that such a procedure is likely to encourage the development of 
arsenic-resistant spirochetes. The rise in temperature that usually follows 
the first injection in florid syphilis is of no serious consequence. 

For the preparation of the solution it is not necessary to employ a normal 
salt solution. Freshly distilled and sterilized water in the proportion of 
20 c.c. of water for each 0.1 of arsphenamine is a convenient solution. 
Higher concentrations, 15 c.c. or 10 c.c. of water to each 0.1 of drug may be 



044 INFECTIOUS DERMATOSES DUE TO PROTOZOA 

used it' the needle be of very small caliber so that the rate of flow is lessened; 
but there is no advantage in this arrangement. The drug must be com- 
pletely dissolved before the alkali is added and the alkalinization should 
be made rapidly and exactly. For each 0.11 of arsphenamine a little less 
than 1 c.c. of a lo per cent, sodic hydrate should be added in a stream and 
the remaining few drops necessary for clearing the solution added slowly 
so that the solution is decidedly alkaline but without needless excess of 
alkali. The solution is filtered through sterile cotton or gauze into the 
burette or irrigator which is to be suspended or held about three feet above 
the point on the patient's arm selected for the injection. The rate of flow 
is an important factor in the production of nervous and vascular reactions; 
the needle should not be larger than 20 gauge; the rate of flow should not 
greatly exceed 0.1 of arsphenamine per minute; the injection of a full dose 
should require about five minutes. 

An examination of the patient's renal function should always precede an 
injection of arsphenamine. In the presence of a marked nephritis, the dose 
of arsphenamine must be reduced to one-quarter or one-sixth the normal 
dose and the effect on the kidneys watched. It is possible that the nephritis 
is syphilitic and that its symptoms will improve after the arsphenamine. 
In general, arsphenamine does very little harm to the kidneys, certainly 
less than a prolonged course of mercury. It is common to find a trace of 
albumin and a number of renal casts in the urine the day following an 
injection. I pay no attention to a good trace of albumin or a moderate 
number of hyaline casts and even a few granular casts. But a considerable 
amount of albumin and many granular casts, more than eight or ten to the 
slide, or epithelial casts may be a contra-indication to immediate further 
treatment. These cases require judgment and careful consideration. 

The night before beginning the course of treatment the patient should 
receive a saline purge. If the treatment is to be administered in the morning 
at about ten o'clock, he is permitted to take nothing more than a cup of tea 
or coffee for breakfast before eight o'clock; after the injection he fasts for 
six or eight hours and may then partake of a moderate dinner avoiding 
heavy and indigestible food. If the injection is to be administered at two 
or three in the afternoon the patient may eat his customary breakfast, 
but should restrict his luncheon to a single cup of tea or clear broth with a 
small piece of dry toast, not later than twelve o'clock; he fasts for six or 
eight hours after theinjection and may partake of a light meal before retiring. 

A course of arsphenamine consists of an intravenous injection of a full 
dose of arsphenamine on each of three successive days. (A course of com- 
bined treatment consists of a course of arsphenamine followed by a four 
to six weeks' course of mercurial injections.) The reactions following this 
energetic treatment with arsphenamine are not greater than those that 
occur after a single injection. In fact, it is only the first of the three injec- 
tions that causes whatever reaction may occur. If the first injection is 
followed by a severe reaction, nitritoid or toxidermic, it would be folly to 
give another the next day ; but these severe reactions are becoming less and 
less frequent. It is my growing belief that most of the severe reactions, 
assuming a reliable arsphenamine, are due to faulty technique: improper 
preparation of the patient, inadequate alkalinization of the solution, its 
too great concentration or too rapid administration. 

After an experience of nearly five years with this method I can state 
first, that it is as safe as any other method of employing arsphenamine; and 
second, that its results are greatly superior to those obtained by other 
met hods of nsiiiji' that remedy. In these statements I have the endorse- 
ment of numerous colleagues who have had experience with this method. 



SYPHILIS 645 

Four courses of the combined treatment should be given during the first 
year after infection, irrespective of the Wassermann reaction. The intervals 
of rest between the courses last six weeks between the first and second and 
eight weeks between the others. If the patient came under treatment 
before the appearance of secondary lesions, the Wassermann reaction will 
probably have remained negative throughout the year and it may be left 
to the judgment of the physician whether or not the treatment be continued 
or the patient simply kept under observation during the next two or three 
years with Wassermann tests every three to six months. It is of course 
safer even though it may be unnecessary to continue treatment during the 
second year with three courses of combined treatment and perhaps two 
during the third year. In the present state of our knowledge it is impossible 
to say; there is no absolute criterion of cure except a re-infection. But 
when the patient has remained Wassermann-negative for a year without 
treatment and a spinal puncture shows no involvement of the central 
nervous system, he may be discharged as probably cured. But even then 
he should be examined serologically at six months' intervals for several 
years. Consent to marriage, however, may be given. 

The syphilitic who comes for treatment in the later stages of his disease 
should receive three courses of combined treatment each year for three 
years. Cutaneous manifestations will heal in a few weeks at most under 
this treatment but visceral lesions do not respond so favorably, especially 
those of the heart and aorta and the central nervous system. Many of 
these cases do not become permanently Wassermann-negative. They are 
nevertheless greatly benefited by treatment and in view of the greatly 
increased sensitiveness of the present-day Wassermann test it is an open 
question whether or not much importance should be attached to the per- 
sistence of a positive Wassermann reaction in old well treated cases. It is 
not possible at present to lay down any general rules. Every case of per- 
sistent Wassermann-positive should be examined by spinal puncture to 
determine the possible presence of asymptomatic syphilis of the central 
nervous system. 

Syphilis of the central nervous system, especially the early stages of tabes, 
always demands energetic treatment. In addition to intravenous injections 
of arsphenamine many syphilographers and some neurologists advocate 
intraspinal treatment. The treatment devised by Swift and Ellis and 
modified by Ogilvie is carried out as follows : 

The patient receives an intravenous injection of arsphenamine. One 
hour later 40 c.c. to 50 c.c. of his blood is drawn aseptically from a vein, 
the blood allowed to clot, its serum separated and placed on ice until 
next day. It is then centrifuged, one-quarter to one-half milligram of ars- 
phenamine in solution added and the serum inactivated at 56° C. for forty 
minutes. It is then ready for use. A lumbar puncture is made, an amount 
of spinal fluid removed equal to the volume of serum, 12 c.c. to 15 c.c, it is 
intended to inject, then 15 to 20 c.c. of the spinal fluid allowed to flow into 
a funnel-shaped vessel where it is mixed with the prepared serum and the 
whole — the spinal fluid plus the serum — is made to flow by gravity into the 
subarachnoid cavity. The patient remains recumbent a number of hours 
after the operation. The injections are repeated at two weeks' interval, six 
to eight injections constituting a course and two courses are given in a year. 
The value of this treatment is not universally admitted; it is my belief, 
however, that cases of tabes in which destructive lesions are not far advanced 
are greatly benefited by intraspinal treatment, symptoms are relieved and 
the disease checked. In paresis which is clinically recognizable little or no 
benefit results from the treatment. An early serological or laboratory 



646 INFECTIOUS DERMATOSES DUE TO PROTOZOA 

diagnosis of paresis has never more than a certain degree of probability. 
The spinal fluid of the paretic always yields a "paretic gold-sol curve," 
together with pleocytosis, albunhnosis and a positive Wassermann, but 
similar findings are observed in other, non-paretic, syphilitic affections 
of the central nervous system and these cases do well under treatment. 

In pregnancy the problem is to prevent infection of the fetus by keeping 
the blood of the mother free from active spirochetes. Before the end of the 
third month of pregnancy when placental circulation is established, energetic 
treatment with arsphenamine and with moderate doses of mercury lest the 
kidneys be injured should be administered; after that period arsphenamine 
and mercury should be given in short courses with short periods of rest; 
one injection of arsphenamine, four weeks of mercury and one month of 
rest. In pregnancy in the asymptomatic Wassermann-positive syphilitic 
of the later stages, the intervals between treatment may be longer.] 

YAWS. 

Yaws — also known as plan and framboBsia tropica — is a contagious 
and inoculable disease of hot countries, which manifests itself by 
crusted papulo- or pustulo-vegetative eruptions and is caused by 
a spirochete. 

Yaws is endemic and widely distributed in Indo-China, certain 
parts of the Indies, the Malaysian Islands, Oceanica, equatorial 
Africa, Central and Southern America. 

After an incubation period lasting from fifteen days to six months, 
the invasion manifests itself by general symptoms, a slight fever, 
digestive disturbances, headache, bone and joint pains and then by 
a furfuraceous scaly itching eruption (Fig. 185). 

In other cases a primary sore known as the yaws-chancre or the 
yaws-matrix develops at the site of inoculation, that is, most 
commonly on the legs or in the face; this lesion may for a long time 
remain solitary or it may blend with a generalized eruption of the 
same type. This so-called chancre really has the same objective 
features as the lesions which follow it (p. 250), frambesia being a 
monomorphous disease. Glandular enlargement is inconstant. The 
eruptions spread over the entire integument, lasting several months 
and following each other during a number of years. The mucous 
membranes invariably escape. There is no alopecia. Visceral 
lesions of yaws are unknown. 

No human race is exempt from yaws. The disease is inoculable 
and extremely contagious, even indirectly, but it is not venereal. 
It is usually contracted during childhood, favored by some excoria- 
tion or ulceration which serves as the portal of entry of the virus. 
Stinging insects may contribute to its dissemination. It is not 
hereditary. In the course of the first weeks or months, auto-inocula- 
tion is still possible; after this time, a relative immunity becomes 
established, which, however, is not always permanent. 

Analogies and a possible relationship between syphilis and yaws 



YAWS 



647 



have Jong been noted, but there are considerable differences: syphilis 
is universally distributed, is not auto-inoculable, has a prescribed 
course and polymorphous, non-pruritic manifestations; it frequently 
involves the mucous membranes and the viscera; moreover, it is 
hereditary. 

The pathogenic agent of yaws, discovered by Castellani in 1905, 
is the spirocheta pertenuis or pallidula; it is a spiral organism, 
morphologically very similar to the treponema of syphilis. Noguchi 
has grown it in cultures. So far it has been found only in the yaws- 
lesions themselves, but not in the blood and the secretions. Yaws 




Fig. 185.— Yaws. Courtesy of Dr. E. B. Vedder (Knowles). 



is inoculable into monkeys and even into rabbits. It does not confer 
immunity against syphilis either in man or animals and syphilis 
on the other hand does not immunize against yaws. But the extract 
of yaws-papules and the serum of human beings or animals having 
yaws or cured of the disease, yields a positive Wassermann reaction. 
The former modes of treatment have been abandoned since the 
surprisingly rapid and complete action of the arsenobenzols has 
been recognized. Sometimes one intravenous injection proves 
sufficient. One month after the introduction of this remedy the 
large yaws-hospitals in Batavia were closed. In countries where 



648 



INFECTIOUS DERMATOSES DUE TO PROTOZOA 



framboesia tropica prevails, the most trifling wounds must be care- 
fully dressed as they might serve as an entrance-portal for the 

infection. 

LEISHMANIOSES. 

Leishmania (R. Ross, 1903) arc protozoa related to the trypano- 
somes, the herpetomonas, etc.; they assume the shape of oval or 
pyriform corpuscles, from '2 to 4^ in length by H to 3/* in width, 
containing two chromatic masses known as the karyosome and the 
centrosome; in cultures they present a flagellate stage. They are 
found particularly in the endothelia, the leukocytes, the connective 
tissue and in macrophagic cells and exceptionally in the blood of 
their hosts. 




Fig. 186.— Orient! 



Oriental Boil (Furunculus Orientalist.- This dermatosis, which 
is endemic in many subtropical or tropical regions in the north of 
Africa. Eastern Asia, Central and South America, also hears the 
names, according to the different countries, of Biskra boil, Aleppo 
boil, Gafsa boil, Nile boil and Delhi boil; Salek or one-year boil in 
Persia, date-boil, and so forth. 

It is characterized by pustular and ulcero-vegetative lesions 
which develop without impairment of the genera] health, most 
commonly in the fall or during the cool season of the year. 

After an incubation of ten days to a month, sometimes longer, a 
red spot makes its appearance, which becomes papular and pruritic, 
resembling a mosquito bite; next, the lesion become covered with 
scales or, as the result of scratching and excoriat ion, with crusts 
which conceal a slowly spreading oozing ulcer with a wavy outline 
(Fig. 186); it frequently has the appearance of a furuncle or crusted 



LEISHMANIOSES 649 

ecthyma before assuming the characteristic features of its adult stage, 
which have been described elsewhere in this book (p. 250). 

The lesions are preferably situated on the exposed parts, the hands, 
the face and the limbs. As a rule, no more than three or four are 
present, sometimes only one, very rarely from thirty to forty; they 
develop in succession and are therefore of different ages. The 
mucous membranes are seldom affected. 

Oriental boil is inoculable and contagious; it confers only a 
temporary immunity. The blood yields a negative Wassermann 
reaction. 

The pathogenic organism discovered by J. H. Wright (1903) and 
named by him helcosoma tropicum was classified by Ii. Ross as 
leishmania tropica or furunculosa. It is very closely related to, 
although different from, leishmania Donovani, which causes kala- 
azar. It is found in thin sections stained with carbolized thionine, 
within the macrophage cells (Nattan-Larrier) ; and more readily 
in smear preparations treated by the methods of Romanovski, 
Giemsa, Laveran, etc. 

It was successfully grown in cultures, in a flagellate form, by Ch. 
Nicolle, who inoculated it into the macacus. Dogs, camels and 
horses are said to offer no resistance to it. Without positive proof, 
it is assumed that the transmission of Oriental boil generally takes 
place through the intermediation of flies, bugs, mosquitoes or other 
stinging insects, especially since Nattan-Larrier was able to demon- 
strate the presence of leishmanias in human blood in the vicinity of 
the lesions. 

The treatment consists either in excision of the lesions or in 
scraping followed by cauterization with the actual cautery or 
applications of potassium permanganate in powder form. The 
efficacy of the arsenobenzols is variously estimated. In Brazil, intra- 
venous injections of antimony tartrate are advocated, in doses of 0.05 
to 0.10, in sterilized solutions of 1 to 100 or 1 to 500 in physiological 
salt solution; these injections actually seem to be very efficacious. 
When the patient leaves the countries where the disease is endemic, 
cutaneous leishmaniosis tends to heal spontaneously; so that in 
temperate zones clean dressings may be considered as sufficient. 
The cure may be hastened by radiotherapy. 

Pian-Bois. — This dermatosis is endemic in Guyana among foresters 
and hunters. Together with de Christmas, I was enabled to observe 
a case characterized by subcutaneous nodules opening on the 
skin as ulcers with a granulating floor; the lesions were situated 
on the back of the hands and arranged at intervals along the lym- 
phatics of arm. The glands become indurated. The course is slow 
and the disease may recur. Nattan-Larrier (1909) discovered the 
pathogenic agent which is a leishmania, present in rather scanty 



650 INFECTIOUS DERMATOSES DUE TO PROTOZOA 

numbers, possessing certain special features and named by him the 
American variety of Leishmania tropica. 

Boubas or Framboesia Brasiliana. -The disease described under 
this name by Breda, B. Summer and others, differs from yaws in 
its course and also in that it less frequently spares the buccal, 
pharyngeal, laryngeal, nasal, conjunctival mucous membranes, 
etc. The initial lesion is a bulla or a pustule, which is followed by 
a superficial slough; next appears one or several ulcero-prolifera- 
tive, painless and non-pruritic lesions in patches; the condition may 
last ten or fifteen years or longer and cause death from cachexia. 
Children are rarely attacked and the contagiousness is apparently 
slight. 

Boubas were attributed by Breda to a bacillus discovered by him 
in the lesions; Fiocco succeeded in growing this bacillus in cultures 
and inoculating it into rabbits. However, Splendore and Carini 
(1911) have shown that the disease represents a leishmaniosis. 

Espundia, described by Escomel, endemic in Peru, Brazil and 
other parts of South America, begins on the limbs or on the trunk 
with a nodule which opens as an ulcer with a granulating floor, 
discharging abundantly and not particularly painful; ulcerative- 
granulating and destructive bucco-naso-pharyngeal lesions next 
make their appearance; the duration is twenty to thirty years. 
Buono de Miranda and Splendore discovered a leishmania which is 
considered by Laveran and Xattan-Larrier (1912) as belonging to 
the American variety of Leishmania tropica. [According to Escomel 
(1919) the lesions of blastomycosis are sometimes associated with 
those of espundia in the same case.] 

Espundia, Bouba, perhaps also Pian-Bois, are therefore probably 
identical diseases, namely Leishmaniasis Americana. 

Injections of tartar emetic are recommended as in the treatment 
of Oriental boil; arsenobenzol is useless. 



CHAPTER XXX. 

DERMATOSES OF THE LEUKEMIAS AND ANALOGOUS 
PATHOLOGICAL CONDITIONS. 

CUTANEOUS LEUKEMIAS. 

In a large number of the skin diseases which have been previously 
discussed, a change in the cellular composition of the blood can be 
demonstrated. Not to mention anemia and leukocytosis which 
are of common occurrence in many infections or toxic diseases of the 
skin and even in the neurodermatoses, it suffices to point out that 
a sometimes very considerable eosinophilia is noted in pemphigus 
and especially in Duhring's disease, where the local eosinophilia is 
still more marked; in cutaneous hydrargyria, likewise with local 
eosinophilia (Hoffmann) ; in leprosy, especially the tubercular form ; 
it has finally been reported in some cases of erythema, urticaria, 
eczema, etc. However, the relations between these eruptions and 
the modification of the blood are neither absolutely constant nor 
probably direct. 

The cutaneous affections to be dealt with in this chapter are on 
the contrary closely related to organic alterations of the blood or, 
more accurately speaking, with one or other of the hyperplastic 
diseases of the hematopoietic organs which are grouped under the 
heading of leukemias and analogous pathological conditions. It is 
therefore indispensable for the dermatologist to be informed on the 
subject of these general diseases. 

Since the investigations of Ehrlich, a distinction is made between 
two fundamental forms of leukemia: (1) The lymphatic leukemias 
in which the hyperplasia affects the glands and adenoid structures 
of the same kind, tonsils, closed follicles of the intestine, thymus, etc., 
including also the spleen; (2) the myeloid leukemias in which the 
lesions affect the bone-marrow and the myeloid tissues, among 
which the spleen, as an organ of mixed structure, again figures. 

These hyperplasias are accompanied by the passage of their con- 
stituent cells into the bloodstream, sometimes in enormous propor- 
tions, for from 100,000 to over 500,000 white corpuscles per cubic 
millimeter may be found (true leukemias). In other cases, this 
passage takes place to a limited degree and no more than 20,000 to 
30,000 white corpuscles are found in the blood, or even a normal 
number (pseudo-leukemias, subleukemias, aleukemias) : but in all 



652 DERMATOSES OF THE LEUKEMIAS 

cases the customary proportion of the different kinds of white 
corpuscles, the leukocyte formula, is modified, so that there may be 
for example a relative lymphocytosis or submyelemia; all degrees, 
subject to variations, may be observed in the same case; a sub- 
leukemia may even become transformed into a true leukemia. 

The leukemias and pseudoleukemias are chronic diseases, usually 
lasting from two to six years or longer; relatively recent observations 
have shown the existence of a rapid form, leading to death in a few 
weeks or months and constituting acute leukemia. 

There is at present a tendency among hematologists to group 
under the heading of lymphomatosis all the hyperplastic affections 
of the glandular or adenoid system, whether leukemic or not, chronic 
or acute, generalized or localized; and under the heading of myelo- 
matosis those of the myeloid system. The principal forms of these 
are outlined in the following: 

Clinical Forms.— Chronic lymphatic leukemia begins insidiously 
with fatigue, emaciation, hypertrophy of the glands, at first often 
with a submaxillary, parotid and cervical and later generalized 
localization, almost invariably associated with an enlarged spleen 
and sometimes with hypertrophy of the liver. The white corpuscles 
of the blood, greatly increased in number, are lymphocytes in a pro- 
portion of .10 to 95 per 100. Histological examination of the glands 
and other hematopoietic organs shows an enormous hyperplasia 
of the adenoid tissue (lymphadenia) which is swollen and packed 
with practically pure lymphocytes; the other organs and viscera 
may be the seat either of leukemic infiltration or of true lymph- 
adenomas. 

Aleukemic lymphomatosis (also subleukemic or aleukemic lymph- 
adenia, Trousseau's adenia, Hodgkin's disease, pseudoleukemia of 
Cohnheim) differs from the above only by the subleukemic or 
aleukemic condition of the blood. Aside from its progressive and 
generalized form, there exist localized forms limited to certain 
groups of glands (neck, mediastinum, abdomen, etc.) or to an adenoid 
organ (tonsil, intestine), which may develop like a neoplasm and will 
be referred to later. 

Chronic myeloid leukemia, the onset of which is very obscure, 
manifests itself in its stationary stage by an enormous spleen with 
a large liver, without glandular enlargement, and by a pale com- 
plexion; the blood ordinarily contains about 300,000 white corpuscles 
the majority of which are granular (polynuclears and myelocytes 
with neutrophile granules, basophiles and eosinophil , myeloblasts 
and nucleated rv(\ cells); the bone-marrow is gray or whitish and its 
constituents are actively proliferating; there is myeloid transfor- 
mation of the spleen and accessorily a myeloid infiltration of the 
lymphatic system and the liver; there may be myelomatosis of the 



CUTANEOUS LEU KE MI AS 653 

perivascular tissue in the entire organism. The subleukemic forms of 
this disease (submyelemic splenomegalies) are rare and still a subject 
of controversy. 

Acute leukemia, which occurs in a not easily distinguishable 
lymphatic form and a myeloid form, behaves like an acute infection. 
The onset is marked by chills, splenic pains, general fatigue and often 
by angina with persistent fever. The dominating features in the 
clinical picture consist in the following: Sometimes, moderate 
glandular hypertrophies, especially at the neck, reaching the tracheo- 
bronchial glands with mediastinal symptoms or the mesenteric 
glands with hypertrophy of the spleen; other cases are associated 
with hemorrhages, epistaxis, hematemesis, melena, etc., or with 
buccopharyngeal symptoms, angina, pseudoscorbutic gingivitis; 
also nervous disturbances, such as headache, vertigo and asthenia. 
The blood contains over 50,000 white corpuscles, which have reached 
an imperfect maturity, large lymphocytes or lymphoblasts, or very 
polymorphous macrolymphocytes. The lesions of the organs are 
the same as in the chronic forms, but with proliferation and infiltra- 
tion of large undifferentiated lymphocytes. 

Aside from these typical forms of lymphomatosis and myeloma- 
tosis, atypical forms are not very infrequently encountered; such as: 

Regional glandular lymphadenoma, without leukemia, not easily 
differentiated from tuberculous adenopathy; 

Lymphosarcoma of Kundrat-Paltauf, which presents itself as a 
malignant glandular tumor, at first regional, with a tendency to 
become generalized, invading the adjacent organs by infiltration 
and spreading by metastasis {lymphosarcomatosis); it is accompanied 
by a moderate neutrophilia ; 

Chloroma (or green cancer of Aran), characterized by tumors of 
the cranial periosteum and lymphomas of a greenish hue in all the 
hematopoietic organs, with lymphoid or myeloid subleukemia; 

Lymphogranulomatosis (of Sternberg-Paltauf ) , a progressive 
glandular hypertrophy, capable like lymphosarcoma of invasion 
and production of metastases, is differentiated from aleukemic 
lymphomatosis by the presence of yellowish gray points in cross- 
sections and by a mixed lymphoid and myeloid structure analogous 
to the structure of wound-granulations, hence its name of granuloma 
(Benda); it is accompanied by a moderate leukocytosis. This 
pathological type, which has not been extensively studied in France, 
corresponds according to Gravitz and others to the majority of 
cases of Cohnheim's pseudoleukemia and Hodgkin's disease. Several 
authors interpret it as an attenuated tuberculosis, a genuine glan- 
dular "tuberculide." 

Etiology and Character. — The etiology of the leukemias and dis- 
eases of the same group is entirely unknown. 



654 DERMATOSES OF THE LEU KE Ml AS 

They were originally supposed to be of neoplastic character and the 
name of" cancer of the blood" (Bard) was actually suggested for these 
cases. As a matter of fact, the indefinite cellular proliferation of 
certain lymphomas and myelomas, the atypical cell-forms met with 
in certain varieties, the invasion of the vicinity and the metastases, 
the terminal cachexia, closely simulate the malignant tumors. It is 
undeniable that the boundaries between lymphadenomas, lympho- 
sarcomas and sarcomas arc not very sharp at the present writing. 

On the other hand, a large array of facts, notably the existence 
of acute febrile forms of the leukemias is in favor of their infectious 
character. There is in all probability no reason to look for a 
"microbe of the leukocythemias" and isolated findings along this 
line of inquiry have not been confirmed. Cultures and inoculations 
into animals are generally unsuccessful; in a well-marked case of 
acute leukemia, I carried out inoculations of blood and tissue-parts 
into two monkeys without result. But the frequency in the patient's 
antecedents of various infectious diseases, eruptive fevers, anginas, 
especially of syphilis and tuberculosis, as well as the analogy in the 
course of certain lymphomatoses and lymphogranulomatoses with 
the tuberculous adenopathies are suggestive of a less simple inter- 
pretation. Possibly, various attenuated infections or those which 
develop on an allergic soil, excite a reaction which after being at 
first defensive, reconstructive and hyperplastic, ultimately becomes 
atypical, destructive and offensive for tissues of the same kind or 
those which have been invaded in the vicinity or at a distance; the 
process, inflammatory at the onset, might in this way acquire the 
attributes of a malignant neoplasm. 

Cutaneous Manifestations. — These may be observed in all the 
forms, chiefly in the subleukemic or aleukemic lymphomatoses 
(pseudoleukemias), in chronic lymphatic leukemia, in the acute 
leukemias, in the case of lymphosarcoma, lymphogranulomatosis, 
etc. ; they are less common in chronic myeloid leukemia, but never- 
theless undeniable (Brunsgaard, Lian). They do not differ among 
themselves according to the type of disease in which they occur; in 
the very noteworthy and learned contribution of Xanta to the study 
of the lymphodermas and myelodermas (Annales de Dermatologie, 
1912), this author agrees with his predecessors in stating that the 
blood-formula has no bearing on the aspect of the cutaneous lesions. 

Besides being extremely variable and multiple, these cutaneous 
manifestations are often polymorphous in the same case. They may 
be persistent or transitory, delayed or premature, sometimes pre- 
ceding the glandular or splenic enlargement and the changes in the 
blood. 

From an objective point of view, they may be divided into three 
groups: 



PLATE III 



/ 



. 



Leukemic Tumors of the Cheek, Nose and Lobule of the Ear, 
in a Case of Leukemic Lymphomatosis. 



CUTANEOUS LEUKEMIAS 655 

1. Some are of very dissimilar and rather ordinary appearance; 
representing the leukemides of Audry and his pupil Germer (These, 
1902). They consist either of persistent pruritus with dryness of 
the skin; or of pruriginous exanthemas in the form of urticaria, 
sometimes of papular or vesicular urticaria, simulating polymor- 
phous erythema or Duhring's disease; or the lymphadenic prurigo 
of Dubreuilh (p. 495) which is accompanied by papules and licheni- 
fication. Patches of eczematization also occur, probably due to 
scratching, as well as pyodermatitides through superadded infec- 
tion, leaving pigmented macules and small cicatrices. Finally, there 
may be eruptions of purpura with easily provoked hemorrhages. His- 
tology has only rarely been able to demonstrate miliary lymphomas 
in certain leukemides, such as prurigo papules. 

2. Leukemic erythrodermas have been described which do not seem 
to constitute a generic type. Some cases are perhaps generalized 
eczemas; others are premycotic erythrodermas (p. 119) ; finally, some 
(Nicolau, Annates de Dermatologie, 1904) present themselves under 
the aspect of generalized exfoliative dermatitis or of pityriasis rubra 
with relative lymphocytosis. In this connection the famous case of 
Kaposi (1885), entitled lymphodermiaperniciosa. is invariably quoted; 
this was characterized by moist and scaly redness, pruritus, a doughy 
thickening of the skin, followed by cutaneous and subcutaneous 
nodosities which became ulcerated; hypertrophy of the glands and 
of the spleen, genuine leukemia, developed rapidly and the patient 
promptly died; the case was probably one of mycosis fungoides, 
beginning with erythroderma and terminating as lymphatic leukemia 

3. Leukemic tumors and infiltrations are more characteristic. 
There exists a localized clinical form, situated anywhere, but often 
on the face; in these cases, flabby and painless, purplish or brownish- 
red tumors, with a thin smooth skin, traversed by telangiectases, 
are seen to develop on the cheeks, the nose and the ears; the swel- 
lings slowly increase in size, without a marked tendency to necrosis 
and ulceration. I have had occasion to follow a case during fifteen 
years (Plate III). They may be found on the mucous membranes. 
Sometimes, the condition consists rather of diffuse purplish infil- 
trations in which vitropressure shows translucid miliary nodules. 

Another form presents small red, bluish or dusky tumors, some- 
times resembling lepromata. In a case of acute leukemia in a child 
of thirteen years, I noted very numerous nummular lilac patches, 
marking the site of not very prominent dermo-hypodermic nodosities 
distributed over the thorax, abdomen, forehead and scalp. 

The structure of these newformations is that of lymphomata 
or lymphadenomata; small or medium-sized lymphocytes (lympho- 
blasts or macrolymphocytes) fill the meshes of a fine adenoid network 
which is supported by the vascular walls. 



656 DERMATOSES OF THE LEUKEMIAS 

In other cases, which seem to me relatively less uncommon, there 
exist multiple cutaneous tumors, some of which are voluminous 

and occasionally undergo necrosis and ulceration; their structure 
comprises cells of various types, a considerable number having the 
characteristics of the constituents of lymphomata or myelomata, 
although more or less modified and atypical; these cells are enclosed 
in a network with strands of variable thickness, fairly large in places 
and provided with connective-tissue cells. These are cases of 
lymphosarcoma and lymphosarcomatosis, whose relations with the 
leukemias are doubtful and which closely approximate the sarcomas. 

Diagnosis. In a general way it may be stated that whenever the 
physician finds himself confronted with a cutaneous manifestation 
which may be a leukemide, a leukemic erythroderma, or a lympho- 
matous or myelomatous tumor, he should keep in mind the leukemic 
and pseudoleukemic states and look for their symptoms. 

In the presence of a coexisting progressive glandular hypertrophy 
or splenic hypertrophy, with corresponding general phenomena and 
the characteristic lesion of the blood, all doubts are removed. 

When no such coexistence is found at the time of the first exami- 
nation, it is advisable not to discard too hastily the idea of a possible 
relation between the skin affection and an as yet undeveloped 
leukemic state, but this should on the contrary be looked for very 
carefully [by repeated examinations of the blood at intervals of one 
or two weeks]. 

This rule is especially imperative in case of tumors of ambiguous 
character which may be leukemic, lymphosarcomatous or sarcoma- 
tous. Laboratory procedures should be called upon to assist the 
clinical examination; in addition to careful control of the hemato- 
poietic organs by repeated serial hematological examinations, recourse 
must be had to biopsy, either of carefully selected eruptive lesions 
or of tumor fragments and possibly of a lymph gland. Fixing agents 
and stains applicable to the cytological examination of the constitu- 
ents, notably those of the myeloid series, must be employed. 

In attempting to decide between the diagnosis of a lymphoma or 
a sarcoma, for example, the following considerations must not be 
losl sight of: the criterion of the "adenoid plexus" is by no means 
entirely conclusive; it is not always possible to distinguish the cells 
derived from the blood (hematogenous) from the cells originating 
locally in the tissues (histogenetic) ; although it is true in a general 
way that the constituents of lymphomata are merely infiltrated 
into preexisting tissues whereas those of sarcomata replace the 
latter, this is not a reliable feature since the leukemic constituents 
are known to possess the power of local multiplication through 
karyokinesis; one may go so far as to admit, with Dominici and 
others, the possibility of a primary development of lymphoma in the 



MYCOSIS FUNGOIDES G57 

skin, as a mesenchymatous tissue, more particularly around its 
vessels, through a revival of its fetal hematopoietic properties. 

It is only at the expense of persevering investigations along this 
line that we may hope to encounter favorable cases permitting a 
better understanding of the cutaneous lymphomata and myelomata 
as well as their relations with the malignant connective-tissue 
tumors or sarcomata. 

MYCOSIS FUNGOIDES. 1 

Mycosis fungoides was first separated and named by Alibert and 
accurately described by Bazin; it is also known as cutaneous 
lymphadenia of Ranvier, Gillot and Demange and as granuloma 
fungoides of Auspitz. It is a chronic general disease, taking an 
irregular course, almost invariably fatal, relatively rare and of 
unknown nature. 

Symptoms. — Mycosis fungoides manifests itself by very diverse 
eruptions and special tumors of an always identical structure. 

The onset, which is extremely insidious, may take place in four 
different ways: (1) as a generalized and prolonged pruritus, with 
nothing to account for it in the beginning; (2) as polymorphous 
premycotic eruptions, to be described presently; (3) as a premycotic 
erythroderma (p. 119); (4) as primary tumors. 

The polymorphous 'premycotic eruptions are transitory or per- 
sistent; they assume the form of erythematous, roseolar, urticarial, 
circinate or erysipeloid spots or patches; of eczematizations prob- 
ably due to scratching; more rarely, of purpura, crops of vesicles 
or bullae, or of pyodermatitides. Sometimes there are more station- 
ary infiltrated patches known as eczemato-lichenous patches, with 
irregular outlines, continuous or interwoven, slightly prominent, of 
a yellowish or purplish red color, which are the seat of severe itching. 
This surface may be scaly, oozing or crusted; or again, which is 
more significant, it may be criss-crossed as in lichenization. The 
number, the distribution and the duration of these premycotic 
eruptions are too variable to permit of a description. 

In the developed stage, the usual findings are as follows: (1) 
Extensive eczematiform and lichenized surfaces, with edema of the 
skin, diffusely covering the face which thereby acquires a fairly 
characteristic leontiastic appearance; nearly the entire integument 
may be involved, although islands of healthy skin are almost 
invariably demonstrable; (2) infiltrated patches, of a brick red 

1 In the first edition of this book, this disease is discussed under the infectious 
dermatoses; this classification, although based upon undeniable analogies, was not 
supported by proof. I now classify it with the cutaneous leukemias, with which it 
definite affinities, 
42 



658 



DERMATOSES OF THE LEUKEMIAS 



color, of variable extent, with an orange-peel or mammillated sur- 
face; (3) mycotic tumors (Fig. 187). 

The latter, at their onset of the size of a cherry to that of half a 
mandarin orange, originate on one of the preceding lesions or some- 
times in healthy skin; they are more or less soft, of a dark red color, 
hemispherical, not infrequently constricted at their base, umbili- 
cated and indented, so that they have been compared to a tomato; 
they may, however, assume a semicircular, crescentic or polycyclic 
form. They often become ulcerated, through superficial erosion or 
through central necrosis, while spreading peripherally. 




Fig. 187.- 



-Mycosis fungoides. Extensive eczemato-lichenous patches of the back, 
with partially ulcerated mycotic tumor. 



There result enormous ulcerated tumors which may become 
conglomerated and attain the size of an adult's head, or large ulcers 
with a ragged, sanious, gangrenous floor, bordered by a fungoid 
elevation. 

It is a remarkable fact that these tumors may at any stage become 
absorbed and disappear spontaneously, leaving no trace, or being 
followed merely by a soft white cicatrix with a pigmented areola; 
other tumors then form in proportion at different points of the body. 

They are situated especially on the trunk, the face and on the 
first segments of the limbs, 



MYCOSIS FUNGOIDES 659 

The glands are sometimes enlarged early in the disease. From 
the start any preexisting nevi become swollen simulating incipient 
tumors. Alopecia of the affected regions is the rule. 

The course extends over a period of from two to twenty years, 
interrupted by spontaneous remissions which may simulate a cure. 
The patient's strength, complexion, weight and digestive functions 
finally become impaired and death occurs in marasmus or as the 
result of a complication. 

In the form with primary tumors (a tumeurs d'emblee), described 
by Vidal and Brocq, the tumors are discrete and restricted to one 
region of the body, originating in healthy skin or on non-pruritic 
patches, without swelling of the glands ; they may become absorbed 
without ulceration. This type is very closely related to the sarco- 
mata according to Brocq; it also approximates the leukemic 
tumors. 

Pathological Anatomy. — In a contribution of mine to the study of 
the premycotic eruptions (1910), I showed that those which are 
clinically of ordinary appearance, for example eczematous or lichen- 
oid, have nothing unusual in their histology; the demonstrable 
changes of acanthosis, papillomatosis, spongiosis, exocytosis and 
partial parakeratosis are those of eczematization due to scratching. 
A biopsy at this stage of the disease would therefore not help the 
diagnosis. 

Premycotic erythroderma, on the contrary, has a characteristic 
structure (Fig. 29) ; namely, that of the mycotic tumors, but spread 
out as a thin layer in the papillary body; often the intra-epidermic 
cellular nests which are peculiar to mycosis are demonstrable, 
differing through their sharp boundaries from the small islands of 
spongiosis seen in eczema. 

The mycotic tumors are uniformly composed of a tissue of lympho- 
matous appearance, which led the first observers (Ranvier, Gillot, 
etc.) to the assumption of a "cutaneous lymphadenia." A fine 
adenoid network, its strands resting upon the vascular walls, is 
packed with a variety of cells. The great majority of these — 
rounded or polygonal, approximately the size of a polynuclear cell, 
with a round or variably deformed nucleus, with more abundant 
protoplasm than that of a lymphocyte, sometimes containing baso- 
philic granules — seem to be atypical myelocytes of lymphoblastic 
origin. Furthermore, there are found, in variable proportions, 
connective-tissue cells, small lymphocytes, large mononuclears, 
sometimes chorioplasts or giant cells, plasmocytes and mast-cells. 
Pautrier and Fage in an interesting case encountered a large number 
of eosinophiles and mast-leukocytes, apparently formed locally at 
the expense of the lymphocytes. In a general way, there is marked 
predominance of a certain variety of lymphoid cells, with distinct 



660 DERMATOSES OF THE LEU KE MI AS 

polymorphism of the other constituents. Many karyokinetic 

figures are found. 

The epidermis of the tumors is hyperacanthotic at their borders, 
eroded or missing in ulcerated eases. Sometimes large numbers of 
"cell nests" (Fig. 29, a) are found, filled with lymphoid eells. 

The composition of the blood is not uniform in all eases and varies 
in the course of evolution of a given ease. A certain degree of 
anemia and eosinophilia is rather common; neutrophile poly- 
nucleosis is not rare; sometimes, a slight myeloid reaction has been 
noted. The leukemia or leukocytosis which have repeatedly been 
demonstrated in the terminal stage, is difficult of interpretation. 

Nothing very definite is known concerning the character of the 
visceral lesions which have been found rather frequently in the 
lungs, the kidneys, the suprarenals and more rarely in the serous 
membranes, the bone-marrow and the liver of mycotic patients; 
Brandweiner found metastatic tumors in the brain, with the same 
structure as those of the skin. This matter requires further investi- 
gation. 

Etiology and Character. — Mycosis fungoides is known to be neither 
hereditary nor contagious. It is encountered somewhat more 
frequently in men than in women, especially between the age of 
thirty and fifty years. [In the American Dermatological Associa- 
tion's statistics it occurred once in about 3000 cases of all skin 
diseases.] 

The etiology and character of the disease are still problematical. 
A large array of arguments is in favor of its infectious character, 
although no parasitological or experimental proof has so far been 
furnished. To admit its sarcomatous character, with Kaposi, 
means to strain the analogies and to content oneself with a word. 
While it is no longer possible to maintain that mycosis fungoides 
is merely the cutaneous form of lymphadenia, it must be recognized 
that it is nevertheless most closely related to the lymphodermas, 
myelodermas and especially the lymphogranulomatoses which are 
infectious neoplasms. It is especially important to keep in mind 
cases which are known to have terminated in leukemia. Some day 
it ma}' be discovered that mycosis fungoides is based upon a reaction 
of the lymphoid or myeloid apparatus, under the influence of still 
unknown or variable pathogenetic agents. 

Diagnosis. — At the onset a diagnosis may be impossible. The 
persistence of polymorphous erythematous, eczematous, lichenoid 
eruptions or of erythroderma, especially when presenting the feature 
of the edematous infiltration which I have emphasized and when 
associated with severe itching, should arouse a suspicion of pre- 
mycotic manifestations. In such cases, biopsy is necessary, but I 
have already pointed out that the histological lesions are often com- 



MYCOSIS FVNGOIDES CGI 

monplace and possess diagnostic value only in so far as they approach 
those of premycotic erythroderma. 

In the stage of infiltrated patches and tumors, the clinical picture 
is very characteristic; but before making a diagnosis of such 
serious import, it should be confirmed by histological examination 
and blood-analysis. The sero-diagnostic method of complement- 
fixation with an extract of mycotic tumors serving as the antigen, 
proposed by Gaucher, Brin and Joltrain, has yielded encouraging 
but still unreliable results. 

Treatment of Mycosis Fungoides and Cutaneous Leukemias. — The 
periods of spontaneous improvement which are apt to interrupt the 
clinical course of mycosis and the chronic leukemias make it difficult 
to estimate the efficacy of the treatment instituted. It is reasonable 
and entirely indicated to treat the premycotic eruptions, the erythro- 
dermas and the more or less ordinary leukemides locally, according 
to their eczematous or pruriginous appearance, etc., like the analo- 
gous skin affections, often with real benefit to the patient. 

Ulcerated tumors should be cleansed, dressed aseptically, tam- 
poned with camphorated naphthol, etc. Sometimes the absorption 
of tumors and infiltrations has been brought about by means of 
topical applications of pyrogallol, the employment of which neces- 
sitates careful control of the urine; or other reducing agents may 
be used. Surgical removal cannot be recommended. Mercurial 
injections have seemed to me to exert a favorable influence in a few 
cases of premycosis. 

The fundamental methods of treatment, however, superior to all 
others, are represented by arsenic and by radiotherapy. The classi- 
cal employment of arsenic by the mouth or by intramuscular injec- 
tions in progressive doses, is at present replaced by intravenous 
injections of novarsenobenzol; the effect may seem to be favorable, 
but is more apt to be doubtful or negative. 

[In these chronic disorders, the effect of arsenic is developed 
only when the drug is administered in full doses and over a long 
period of time. The arsenobenzols exercise their specific effect in 
syphilis not qua arsenic but because of a peculiar molecular struc- 
ture which renders them spirocheticidal. They are of value there- 
fore only in the spirochetal infections. Their action is necessarily 
too evanescent to be of use when the metabolic effect of arsenic is 
the object of its administration. I have found arsenic by daily 
hypodermatic injections in courses of a month to be of decided value 
in the leukemias, not only in controlling the early eruptions but also 
in favorably modifying the blood-picture. I use the formula 1$ sodii 
arsenatis, phenolis, aa 2.0, aquse 100.0. Beginning with 0.5 c.c, 
the daily dose is gradually increased until it reaches 2.0 or 3.0 c.c. 
at which point it remains stationary for a week, thence declining 



662 DERMATOSES OF THE LEUKEMIAS 

rapidly. The course lasts about a month and may be repeated after 
a two months' interval. The injections are absolutely painless.] 

On the other hand, it is unanimously conceded that radiotherapy 
is the treatment of choice in all the diseases of this group. In 
different cases the glandular masses, the spleen, the bones, or again 
the tumors or the various cutaneous lesions are exposed to the rays, 
with or without filter, in carefully regulated doses, using caution 
and judgment. The rapidity with which the hyperplasias are 
reduced and the tumors or infiltrations made to disappear, while 
the leukocyte formula of the blood becomes modified is very remark- 
able and has encouraged great expectations. It may be stated that 
although a noteworthy improvement and sometimes more or less 
lasting apparent cures are thus obtained, no certain and definite 
cures have as yet been reported. 



CHAPTER XXXI. 
TUMORS OF THE SKIN. 

Tumors or neoplasms are circumscribed, non-inflammatory new- 
formations having a tendency to persist and increase in size, of 
unknown etiology. 

The group of tumors was formerly more comprehensive than it is 
at the present day, for originally all swellings were grouped under 
this heading; for a very long time, until the discovery of their 
infectious character, the tuberculomas, syphilomas, lepromas, acti- 
nomycosis and so forth, ranked as tumors. In a general way, 
this is a provisional group; as soon as a neoplasm has surrendered 
the secret of its origin, it ceases to be considered as a tumor and 
is aligned with the infectious or other diseases; for this reason I 
regard as justified the introduction of the words "of unknown 
etiology" into the terms of the definition of neoplasms. 

In a certain number of tumors, although their first cause still 
escapes us, the pathogenic mechanism to which they are referable 
can nevertheless be suspected. As a matter of fact, there are alto- 
gether only three conceivable mechanisms capable of giving rise to 
pathological neoplasms. These must necessarily be due to: either 
an original malformation; or to a reaction of the tissues against 
external injurious agents, a reaction which is described as inflam- 
matory; or finally to the deposit or retention of elaborated or 
secreted autochthonous substances. 

Among the tumors of the skin, a considerable number belong to 
the first group, namely the nevi. 

Others are almost certainly, in spite of the terms of the above 
definition, of inflammatory or infectious character, as results from 
their contagiousness or from their structure; such are the warts, 
molluscum contagiosum, perhaps certain sarcomas, etc. 

As retention tumors may be cited the sebaceous cysts, the 
xanthomas, the tophi of gout; and perhaps urticaria pigmentosa. 

As to the majority of neoplasms, however, for example, epithelial 
cancers, their origin remains as yet inexplicable. Furthermore, it 
must be kept in mind that in the ultimate analysis the three processes 
are perhaps neither irreducible nor incompatible. It has actually 
been shown that imperceptible transitions occur between the 
inflammatory hyperplasias, the nevus-like malformations and the 
retention-tumors. 



064 TUMORS OF THE SKIN 

On the other hand from the point of view of their clinical behavior, 
although sonic tumors arc benign, behaving simply like an acquired 
and persistent local deformity, and others are malignant, destructive, 
invasive and subject to dissemination by metastasis, all intermediate 
degrees between these two courses are met with, as well as transi- 
tions from one form into the other. 

On the whole, although it comprises extremely dissimilar affec- 
tions, this nosographical group of tumors must still be provisionally 
maintained for the time being. 

Several classifications, clinical, anatomical, pathogenic, have been 
suggested and can be combined to a certain extent. I shall therefore 
subdivide this class into three orders: 

1 . Nevi, the nevic tumors really belong anatomically to one of the 
two following groups; but, it seems to me desirable to present a 
general survey of these malformations, whether they constitute 
neoplasms or not. 

'2. Epithelial tumors. 

3. Connective- and Vascular-tissue tumors. 



NEVI. 

Nevi — popularly designated under the names of birthmarks, 
portwine stains, liver spots, beauty spots, etc. -are congenital mal- 
formations of the skin, assuming the form of persistent spots or, 
tumors. Such is their classical definition. 

It has long been known, however, that these deformities are by 
no means strictly congenital and unchangeable. Many nevi spread, 
enlarge or diminish in size. Some do not appear until after birth, 
at the time of puberty or even later. Nor is there any valid reason 
why the name of nevi should not be applied to certain entirely 
analogous spots or outgrowths which do not develop until adult 
life or in old age. 

Nevi would therefore be more accurately defined as circum- 
scribed deformities of the skin, of embryonic or developmental 
origin, appearing at any age and taking a very slow course. 

The view according to which nevi are dependent upon emotional 
or physical disturbances experienced by the mother during preg- 
nancy, rests on no solid basis. 

Nevi arc of enormous frequency. Individuals entirely free from 
them are exceptional. The hereditary character of a predisposition 
for nevi is very obvious and in certain families they arc remarkably 
abundant. 

Numerous or large nevi are not infrequently met Avith in erratic 
or feeble-minded persons and idiots, so that they have been desig- 
nated by some as a hallmark of degeneration, an obviously exag- 
gerated statement. 



MevI 665 

It must be understood that in some cases it is not a question of 
solitary and as it were accidental products, but of profuse sometimes 
regional or systematized eruptions of nevi of various types, asso- 
ciated Math other malformations: Recklinghausen's disease, lenti- 
ginosis, perhaps xeroderma pigmentosum, etc., to which this remark 
is applicable, may be considered as nevic diseases. 

Four forms of nevi are recognized: (1) Pigmentary nevi; (2) 
tuberous non-vascular nevi; (3) adenomatous nevi, in which some 
of the cysts may be included; these will be discussed with the 
epithelial tumors; (4) vascular nevi, which will be found under the 
heading of angiomas. 

1. Pigmentary Nevi. — These are brown or blackish spots, without 
notable thickening of the skin, of variable shape and dimensions; 
they may apppear at any age but especially about puberty; they 
are apt to darken or multiply under the influence of pregnancy, 
uterine disturbances, or exposure to sunlight. 

(a) Liver spots, thus named on account of their color, are round, 
oval, or polylobular and may exceed the dimensions of the palm of 
the hand; aside from its pigmentation, the skin is in no way changed. 

(b) Ephelides (p. 323) are not classified with nevi by the 
majority of authors. 

(c) Lentigo or lentigines are brown, black or blue spots, about the 
size of a lentil, situated on the face, the neck, the shoulders or else- 
where; they are sometimes known in France as "beauty spots." 
The old writers designated the purely pigmentary flat spots under 
the name of ncevi spili. Not uncommonly, however, a lentigo is 
perceptible to the touch and slightly prominent; all intermediate 
forms may even be met with between lentigo and soft pigmentary 
verrucous nevi. In the flat spots of lentigo, the pigment is localized 
in the epidermis exclusively; when the spots are prominent, pig- 
mentary and nevic cells are found both in the epidermis and in the 
cutis (Fig. 195). 

Exceptionally, the skin is spattered with lentigo-spots in the form 
of an abundant eruption, constituting lentiginosis prof it sa. 

(d) Lentigo maligna (infective melanotic freckles of Hutchinson; 
precancerous circumscribed melanosis of Dubreuilh) is a pigmentary 
spot which may appear at any age, by no means exclusively in the 
aged, in any region, although preferably on the face. It has the 
structure of a diffuse lentigo, spreads slowly at first, then sooner or 
later gives rise to a nevo-carcinoma and accordingly constitutes an 
extremely serious affection. 

(e) In progressive cutaneous melanosis, a very rare disease which is 
more apt to attack the young, a slate-colored or bluish spot is seen 
to spread slowly, become verrucous, give rise to melanotic infil- 
tration of the glands and lead to death after a number of years as a 



606 TUMORS OF THE SKIN 

result of visceral melanosis. In this form, the pigment infiltrates 
the connective-tissue cells of the corium. 

The treatment of liver-spots is like that of ephelides. It would be 
exaggerated to insist upon the destruction of all lentigo spots, but 
it is advisable to watch them. 

At any rate, it should be kept in mind when treating lentigo, that 
there is real danger in repeatedly irritating or incompletely cauter- 
izing the spots, for such measures result only too frequently in the 
production of melanosis and nevus-carcinoma. (French Association 
for Cancer Research, November, 1913.) Superficial spots can be 
destroyed with the galvanocautery ; carbonic acid snow or electrolysis 
constitute the treatments of choice. Deeper spots are to be de- 
stroyed exclusively by electrolysis. Where there is the slightest 
indication of extension or malignant change, early wide excision is 
the only recourse. Radiotherapy and radium are not to be recom- 
mended. 

[Any method of treatment which does not insure the removal or 
destruction of every single nevus-cell must be condemned. The 
cells left in the scars produced by electrolysis or other methods of 
cauterization are subject to great irritation from the strain of the 
scar-tissue, and the methods in question necessarily involve the 
risk of leaving a few cells intact. In practice no harm results in 
the majority of cases; but I have seen three cases of cancer devel- 
oping in nevi treated by electrolysis or C0 2 -snow. A pigmented 
nevus should be left in peace or else radically, surgically, removed.] 

2. Tuberous Non-vascular Nevi. — These are not simply spots 
but genuine neoplasms of variable dimensions. 

(a) Soft verrucose nevi (soft warts, cellular nevi). — This name is 
applied to elevations of the size of a hemp-seed to that of an almond, 
more or less prominent, sometimes slightly constricted at their base; 
the surface is smooth or grained, sometimes hairy; the color is pink, 
yellowish or dusky. Soft warts may be congenital, but appear more 
frequently during childhood, increasing in size with the approach 
of old age. They are especially common on the face, the neck, the 
thorax and in the neighborhood of the external genitals. 

Their chief importance lies in their possible transformation into 
cancer when they are exposed to repeated irritation or unskilful 
cauterizations. 

Histological examination shows that these nevi consist of an 
infiltration of the cutis by round or polyhedric cells with a large 
nucleus, abundant protoplasm, distinctly epithelioid, solitary or 
arranged in nests, columns or strands, representing the nevus cells, 
which are sometimes pigmented. Virchow interpreted these 
cells as young connective-tissue cells; Demieville, as endothelial 
cells; Unna showed that they are epithelial and derived from the 



NEVI 667 

rete mucosum of the epidermis through proliferation and strangu- 
lation of the interpapillary processes. This statement has been 
verified by numerous authors and I too have been able to confirm 
it. The epidermis itself is often found to contain nests or clusters 
of pigmented or non-pigmented nevus cells (Fig. 185). Hence the 
malignant tumors which arise from these soft warts through prolifer- 
ation of the nevus cells can no longer be regarded as sarcomas of 
connective-tissue origin, but rather as epitheliomas of a special 
kind, nevo-carcinomata. 

(b) Nevi Molluscum. — These are more flabby formations than the 
soft warts, with a thin epidermis and a wrinkled surface. These 
mollusca may be flattened and spread out, yielding the sensation 
of a depression in the cutis on palpation; or they may be slightly 
prominent, like lipomas ; more frequently they are pedunculated and 
are then called molluscum pendulum. 

The latter, which are very common, develop in the period of 
adolescence or sometimes in large numbers in the forties; they are 
chiefly situated on the neck, the back, the eyelids and around the 
genital regions. Their size varies from that of a pin-head to a pea, 
often reaching that of a raisin, berry or a small pear. [Crops of these 
small pendulous fibromata, 50 to 100 or more in number, some- 
times develop in women on the face, neck and torso, during the 
later months of pregnancy, disappearing for the greater part in the 
course of a year or two, constituting therefore a form of dermatosis 
of pregnancy. ] 

Fibroma molluscum; some voluminous nevi molluscum form 
large flabby tumors, either not very prominent and lobulated or on 
the contrary hanging down in the shape of a wallet, sometimes 
reaching the dimensions of an orange or a child's head. 

When they enclose hard nodular strands, which usually are 
thickened nerves, they bear the name of plexiform neuromas. 

In a considerable number of cases, the large number of nevi 
molluscum or the mere presence of fibroma molluscum may suggest 
the existence of an incomplete or abortive form of Recklinghausen's 
disease which will be described further on. 

All these nevi molluscum are histologically made up of a special 
fibromatous tissue, with fine connective-tissue fibers and very 
numerous young cells, without an elastic plexus. They practically 
never undergo a cancerous change [but myxomatous degeneration 
is frequent]. 

(c) Hard or Hyperkeratotic Verrucous Nevi. — These have been 
described with the circumscribed keratoses (p. 206). Their structure 
is that of generalized hyperkeratosis; nevus cells are only rarely 
present. 

I repeat that they may assume an arrangement as linear streaks, 



668 TUMORS OF THE SKIN 

or ;is osteo-follicular keratoses (p. 4(K>); and finally, the appearance 
known as porokeratosis, when they affect the palmar or plantar 
regions (p. 216). 
(d) Hairy Nevi (New, Pilosi). — An exaggerated development 

of the hairs, their follicles and their sebaceous glands, may be 
encountered in the pigmentary nevi and in all the varieties of non- 
vascular tuberous nevi. These hairs are often thick or enormous, 
dark and curly, more or less abundant; giant comedos, sebaceous 
cysts or small horny cysts may also be seen. Hypertrichosis in 
spots or on larger surfaces, which may constitute a partial furry 
coat, must be included with the hairy nevi (p. 405). 

Treatment. — What has been stated about the treatment of lentigo 
is strictly true in all respects for the soft warts. Electrolysis is by 
far the best mode of intervention and yields the best esthetic results. 
The treatment of the other varieties is optional; according to the 
cases, they may be dispersed or removed with the galvano-cautery, 
the bistoury, carbonic acid snow, etc. [I have already stated my 
objections to any except radical treatment for these conditions.] 

Neurofibromatosis or Recklinghausen's Disease. — This is a typical 
developmental and, strictly speaking, nevic disease, sometimes 
familial, having its principal manifestations in the skin and the 
hypoderm (Fig. 188). 

Neurofibromatosis is characterized by four sets of symptoms: 
( 1 ) Pigmentations, under the form of liver spots, lenticular spots and 
regional or diffuse melanoderma; (2) cutaneous tumors, scattered 
in one region or over almost the entire body, being nevi molluscum 
of all varieties and dimensions; they often begin in the hypoderm, 
where they may be recognized by a bluish spot and by their con- 
sistence; they protrude after the fashion of a hernia through the 
cutis and later on become pedunculated; (3) tumors of nerves, 
assuming the form of hard, rounded or spindle-shaped, sometimes 
moniliform nodes, perceptible along the course of the subcutaneous 
nerve-filaments of the forearm, the flanks, the forehead, the neck, 
or the thighs; they are due to the development around the nerve- 
sheaths and especially in the interior of the latter, of a tissue like 
that of fibroma molluscum; (4) mental disturbances, consisting of a 
general intellectual deterioration or loss of emotional control. |In 
my experience mental disturbances are extremely rare.] 

Numerous incomplete cases occur, in which either the tumors of 
the nerves or the pigmentations, etc., are absent. The pigmen- 
tations are of such characteristic appearance, through the associa- 
tion of the three forms mentioned above, that when they are the 
only symptoms present, a diagnosis of Recklinghausen's disease is 
sometimes justified. 

In other cases, some of the tumors assume a considerable size 



EPITHELIAL TUMORS 



0(i9 



and are then designated as major tumors. They present the appear- 
ance either of fibroma molluscum or of plexiform neuromata, or 
even of dermatolyses (p. 372). 




Fig. 188. — Neurofibroma. Vor^ Recklinghausen's disease. (Ormsby. 



Neurofibromatosis appears in the course of childhood or adoles- 
cence, develops in successive instalments and then persists indef- 
initely. Distinct retrogressions have, however, occurred in my 
experience. 

EPITHELIAL TUMORS 

The tumors derived from the epidermis or its adnexa, hair follicles 
and glands, consist in part of simple tissue hyperplasias, in part of 



670 TUMORS OF THE SKIN 

hyperplasias with metaplasia or metatypism, i. c, a more or less 
pronounced modification of the normal cell type. The statement is 
justified only in a very general way that the former follow a usually 
benign course, whereas the latter are as a rule of malignant character. 

As a matter of fact, the conditions governing the malignancy of 
tumors, their tendency to indefinite invasion and generalization, 
are entirely unknown at the present time. 

Papillomata. — The attempt has been made to group under this 
term all outgrowths resulting from a proliferative hypertrophy of 
the epidermis (p. 237). In reality, the term papilloma is appli- 
cable only to an objective appearance. To state that a cutaneous 
or mucous lesion is a papilloma is no more equivalent to a diagnosis 
than it would be to describe a disease as a papule or a bulla, but it 
simply describes an existing dermatological lesion. This derma- 
tological form, to which Chapter XII is devoted, may manifest 
itself under a great variety of conditions. 

Common and flat warts, as well as venereal warts, are almost 
certainly of infectious origin. The same is true for a considerable 
number of the other proliferative dermatoses. Verrucous nevi are 
papillomas resulting from a local malformation. 

In the angiokeratomas (p. fi95) the verrucous condition is sec- 
ondary to the angiomatous newformation. 

It is an important and noteworthy fact that certain epitheliomas 
are papillary or begin with a proliferative stage of papillomatous 
appearance. 

Cysts. — Cysts are neoplasms of a special variety and result, not 
from an abnormal multiplication of living constituents, but from an 
accumulation of inert secretory products in an epithelial pocket, 
lined with a connective-tissue membrane; accordingly, they repre- 
sent retention tumors. A distinction is made between two classes: 

A. Epidermic and Sebaceous Cysts. — Their size varies from that 
of a millet-seed to that of a hen's egg; they are intradermic or 
hypodermic. Their consistence may be hard and elastic, or flabby, 
or even fluctuating. The skin which covers them may be raised or 
stretched, but usually retains its normal color; it becomes red- 
dened in case of inflammation. 

The contents of these cysts are opaque and pasty, made up for 
the most part of more or less perfectly keratinized epidermic cells, 
derived from their internal lining, which is epidermic; they also 
contain fat, a direct product of the developing epidermic cells; 
fatty acid crystals, soaps, cholesterol and sometimes particles of 
lime salts. According to its appearance, the contents are described 
as meliceric, steatomatous, cholesteatomatous, or oily. Suppuration 
of the cysts caused by infection through pyococci, may lead to a 
cure. 



EPITHELIAL TUMORS 671 

There are five varieties to be described: 

1. Follicular cysts and sebaceous cysts, generally resulting from a 
dilatation of the pilo-sebaceous canal. Their first stage is represented 
by comedo; when more advanced they form little yellowish-white 
elevations which are superficial, umbilicated, pasty cysts that may 
be emptied by expression. 

2. Dermoid Cysts. — These are derived from an epidermic inclusion 
in the region of certain embryonic clefts and are consequently 
situated especially at the outer end of the eyebrows, in the neighbor- 
hood of the orbit, on the neck, on the perineal raphe, the scrotum, 
etc. They may contain hair follicles, hairs, sebaceous glands, etc. 

3. Wens. — These are sebaceo-epidermic cysts, frequently multiple, 
met with only on the scalp and on the scrotum and appearing only 
in adult or aged individuals; they are deep and present neither an 
umbilication nor an orifice. In my opinion, wens are derived from 
a congenital malformation of folliculo-glandular epidermic buds 
and should be interpreted as a variety of nevi; constituting cystic 
follicular adenomatous nevi. 

4. Traumatic Epidermic Cysts. — These are hard, round, painless 
tumors, which are encountered only on the palmar aspect of the 
hands and fingers. These cysts seem to result, according to the 
explanation offered by Gross of Nancy, from a deep implantation of 
a shred of epidermis, under the influence of a traumatism. They 
are observed especially in laborers and require months and weeks 
for their development. 

5. Milium. — The name of milium, or grutum, is applied to white, 
beady granules the size of a pin-head, which are small epidermic, 
intra-epidermic or intra-dermic cysts. They are observed as a 
primary manifestation especially on the upper two-thirds of the face 
and on the genital organs of both sexes; or secondarily upon cica- 
trices of no matter what origin ; or as a sequel of bullous affections, 
especially congenital pemphigus with epidermic cysts (p. 191). 

Histology shows them to result from the dilatation either of 
sudoriparous canals or hair follicles. Primary milium is a sort of 
cystic nevus; the milium of cicatrices is a retention-tumor. 

The treatment of all these epidermic cysts, if any is required, con- 
sists in their removal with the bistoury when they are large or with 
the curette in the case of milium. Wens may also be treated by 
injecting into their interior a few drops of pure ether, or ether with 
bichloride of mercury, or a zinc chloride solution; this injection to 
be several times repeated. At the time of the spontaneous elimina- 
tion of the cyst, which takes place at the end of eight or ten days, 
attention must be given to the thorough extraction of the entire 
epidermic shell. 



(172 Tl MORS OF THE SKIN 

B. Serous Cysts. Aside from the hygromas, the branchial cysts 
of the neck and of cysticercus cellnlosa which are not cysts of 
epidermic origin, this class comprises only a single type: 

Hidrocy stoma. Hidrocystoma was pointed out by A. Robinson 
in 1884 and 1893 as a tense, firm, translucid elevation, from which a 
watery fluid is discharged on puncture; it is the size .of a pin-head 
ni- a pea and develops in large numbers on the face, chiefly in 
middle-aged women who are exposed to the heat of stoves, etc. 
Hidrocystoma has a tendency to disappear in the winter, reappear- 
ing in the spring. The little tumor consists of a dilatation of a 
sudoriparous canal and is in my opinion of nevic character, there- 
fore constituting cystic sudoriparous adenomata. Needless to say, 
they have nothing in common with dysidrosis and sudamina. 

Adenomata. — The name of adenoma is at present applied to 
benign epithelial newformations, of glandular origin, whose con- 
stituents more or less accurately reproduce the texture of the 
glands from which they are derived. 

The adenomas of the skin are subdivided into sebaceous adenoma 
and sudoriparous adenoma or hidradenoma. All appear to have a 
congenital malformation for their origin and the name of adenoma- 
tous new, is eminently adapted to them. 

Adenoma Sebaceum. — The most interesting form is represented 
by the .symmetrical sebaceous adenomas of the face. They appear 
under the aspect of innumerable small tumors, the size of a millet- 
seed to a large pea, occupying the nasogenial grooves and their 
neighborhood, the root of the nose and the forehead, the chin, some- 
times the vicinity of the auditory meatus, the scalp, etc. (Fig. 189). 
These adenomas, which are rarely congenital, appear in late child- 
hood, gradually increasing and persisting indefinitely. A white 
variety, Balzer type, is known, in which the sebaceous glands under- 
go an atypical proliferation; a red and soft variety, Pringle type, 
with glandular and vascular hyperplasia; and a hard variety, 
Hallopeau-Leredde type, in which I was able to demonstrate the 
predominance of fibrous tissue, so that this condition should rather 
be described as a fibro-vascular nevus. [Adenoma sebaceum is 
often associated with other congenital malformations. Several 
cases of association with multiple subcutaneous fibromas, teratoma 
of a kidney and mental disorders have been recorded.] 

Nonsymmetrical sebaceous adenomas are seen in aged persons 
or adults, scattered in variable number especially on the scalp, the 
face, or the back, from the size of a lentil to that of a nut or larger. 

The heterotopic sebaceous (/lauds of the mucosa' may be considered 
with the adenomata; they arc not infrequently seen in the mouth, 
on the internal aspect of the lips and cheeks. They have the appear- 
ance of very small, hardly protuberant spots, the size of a pin-point 



EPITHELIAL TUMORS 



673 



or head, of a golden yellow or cream yellow color, solitary or in 
abundant crops. They do not develop until after puberty. In 
America this anomaly is described under the name of Fordyce's 
disease. It is of interest only on account of the diagnostic errors 
to which it may give rise, in the differentiation from buccal lichen 
planus, etc. 




Fig. 189. — -Symmetrical sebaceous adenoma of the face, Balzer type. 



Hidradenoma. — These small neoplasms — also designated as syringo- 
cystadenoma, etc. — have two seats of predilection : 

1. On the anterior surface of the thorax and the neck, where we 
described them with Jacquet, under the name of hidradenomes 
eruptifs; they are rare, appearing between the age of ten and 
twenty years, as numerous solid, often oval protuberances of a 
pale pink color, resembling syphilitic papules, but not scaly; they 



674 



T l MORS OF THE SKIS 



lasl indefinitely or may disappear. Lesions of the same nature may 
also be found scattered over the abdomen, on the arms and on the 
face. 

2. Hidradenomas of the lower eyelids arc certainly much more 
common. They are met with especially in adult or aged women. 
They arc of the color of the skin, the size of a pin-head (Fig. 190) 
and must not be confused with xanthelasma of the eyelids. 

In both cases the structure of the hidradenomas is characteristic; 
the corium is found to contain cylindrical and branched epithelial 
strands, dilated here and there into very minute cysts. They are 
practically unanimously referred at present to an abnormal prolif- 
eration of rudimentary undeveloped sweat-glands. The interpre- 
tation implied by the name of lymphangioma tuberosum multiplex, 
given by Kaposi to these small neoplasms, is obviously erroneous. 




Fig. 190. — Hydradenoma ot the eyelids. 



The treatment of adenomas in general consists in ablation with 
the bistoury when they are very large. Small adenomas, if the 
patient desires their removal, should be treated with electrolytic 
punctures, or when this is not practicable with the curette and the 
galvano-eautery. 

Molluscum Contagiosum. — This designation, due to BatCman — 
and preferable to the names of acne varioliformis, Bazin; molluscum 
sebaceum, Hebra; epithelioma contagiosum, Neisser, etc. — is applied 
to peculiar small epithelial tumors which are neither adenomas nor 
epitheliomas. 

Molluscum contagiosum presents itself as small hemispherical 
prominent elevations of a milk-white, pearly or pink color, their 
i ssential feature being that they are umbilicated on their crest. 
Their size varies from that of a pin-point to that of a very large pea; 
they may become conglomerated into a tumor as large as an almond, 
which has a tendency to become pedunculated. By compression 
between two fingers a creamy or pasty mass can be scmeezed out 



EPITHELIAL TUMORS 



675 



of the umbilicus, consisting under the microscope of horny cells and 
of refractive ovoid corpuscles, the so-called molluscum bodies. 

The tumors, which vary greatly in number from a few units to 
several hundreds, are of variable dimensions and appear insidiously, 
in successive crops. They are scattered on the face, especially on 
the eyelids, the neck, the genitals and their neighborhood, but may 
be found anywhere (Fig. 191). Left untreated they persist indefi- 
nitely, without any subjective symptom, multiplying through auto- 
contagion; some of the tumors may become inflamed, suppurate 
and disappear. 




Fig. 191. — Molluscum contagiosum of the region of the knee. 



Molluscum is observed [most frequently] in children and in youth- 
ful individuals of both sexes with a delicate skin. 

Its contagiousness is undeniable; Vidal, Retzius, Hanau and 
others have successfully inoculated them; the incubation takes 
several months. [Wile and Kingery have reproduced them by 
intracutaneous injection of a filtrate (Berkefeld) of macerated 
molluscum turn or. J 

Histology shows molluscum contagiosum to be formed by fairly 
regular pyriform epidermic lobes with their small extremity turned 
toward the umbilication. Notwithstanding the gross analogy of 
their configuration, it is an established fact that these tumors never 
develop from sebaceous glands. The Malpighian cells of the 
lobules in proportion as they are pushed back toward the umbilicus, 
undergo in part a keratinization with eleidine, while others undergo 
special changes transforming them into molluscum bodies of ovoid 
shape, which present the reactions of colloid or keratoid substances. 



676 TUMORS OF THE SKIN 

Their special interest lies in the misinterpretation of these bodies 
as psorospermia or coecidia, a view which has been proved false. 

The condition actually is a special dyskeratosis, related to that 
observed in psorospermosis follicularis and Bowen's disease. The 
corpuscles are not the carriers of the contagium; Juliusberg and 
Borrel have shown that the virus of molluscum contagiosum is 
filtrable. 

The best treatment is extirpation with the curette, which is easy 
and leaves no cicatrices. [Expression between two thumb-nails is 
simple and effective.] Into the small tumors which have first been 
emptied by expression, the end of a pointed match dipped in tinc- 
ture of iodine may be introduced. When the tumors are small and 
very numerous, applications of iodine tincture, soft soap, or cam- 
phorated alcohol may prove sufficient. 

Epitheliomata. — Cutaneous epitheliomas are tumors resulting from 
an atypical proliferation of the epidermis and of its adnexa. They 
have also been designated by the names of epithelial cancers, 
cancroids, formerly as polyadenomas, erosive ulcers, noli me tangere; 
abroad, especially in Germany, they are all grouped under the head- 
ing of carcinomata, whereas in France the latter term is reserved 
for the malignant and invasive cancers. 

In the following brief account I shall include the epitheliomas of 
the buccal cavity as well as those of the external genital organs, etc., 
which are equally of dermatological interest. 

Among the highly multiple clinical forms of epithelioma, some 
possess extreme malignancy while others on the contrary are abso- 
lutely benign. These will have to be very carefully differentiated. 
It must be emphasized, however, that even epitheliomas of a 
malignant character begin as a rule as an apparently insignificant 
lesion, readily amenable to early treatment. There is no knowledge 
of greater practical importance for the physician than familiarity 
with the mode of onset of cancers; when properly forewarned he 
will know how to caution his patients against the possible gravity 
of a trifling "sore" and to rid them of it in time. 

Clinical Forms. — The attempts which have been made to find in 
the histological structure of the various forms of epitheliomas an 
explanation of their widely divergent course have been only partially 
successful. The classification which I proposed at the International 
Congress in 1904, although based upon the histological structure, 
takes largely into account the objective features and the develop- 
mental tendencies of each kind, namely those characteristics which 
possess the greatest practical importance. This classification is 
here repeated. 

1. Lobular or Spinocellular Epithelioma. — In this first class, the 
neoplastic masses are usually arranged in elongated and enlarged 



EPITHELIAL TUMORS 677 

interpapillary buds, or in lobules and in wide strands; they are 
made up essentially of Malpighian, prickle or spinous cells; these 
cells undergo the usual epidermic evolution, with formation of 
keratohyaline, becoming keratinized into horny cells and often into 
epidermic pearls. This class is subdivided into two types: 

A. Superficial Proliferative Type or Papillary Epithelioma. — This 
type comprises: 

(a) Homy papillary epithelioma, which develops in healthy skin, 
or not infrequently on a senile keratosis. It is encountered in all 
regions but especially in the face, on the lips, the neck, the back 
and on the dorsal aspect of the extremities. It begins as a verrucous 
elevation and persists a long time in this condition; then, almost 
invariably in connection with traumatism, it spreads as a protuber- 
ant disk bordered by a raised and hem-like margin, the center being 
studded with villous elevations covered by adherent horny crusts. 
The glands remain intact for a long time. This epithelioma bleeds 
readily, may ulcerate and finally leads to cancroid. 

(b) Cornu cutaneum — that is to say, senile horny excrescences, 
for there exists a juvenile form belonging to the class of hyper- 
keratotic nevi (p. 206) — is a papillary epithelioma with exuberant 
hyperkeratosis. These horns are of extremely variable size and some- 
times resemble a ram's horn from every point of view, including 
the curvature. They develop in healthy skin or on senile keratosis, 
chiefly in the face, on the scalp, the glans and the prepuce. Their 
base may be surrounded by a rose-colored border. Their growth is 
usually very slow; when they fall out or are removed, they will 
grow again. The histological lesions are those of papillary epithe- 
lioma, more or less pronounced; the horn itself is formed by agglu- 
tinated cellular columns; it is softer in its center. These growths 
may develop into cancroid and this contingency must be kept in 
mind for the treatment. 

(c) Naked papillary epithelioma, without a horny covering, is met 
with on the lips, the buccal mucosa, the glans and the vulva; its 
surface is red, velvety and glistening. It follows a slow and for a 
long time benign course, but may become ulcerated and pass into 
cancroid. 

It is necessary to guard against confusion of this variety of 
epithelioma with the proliferative syphilides, with tuberculous lupus 
of the mucous membranes, etc. Examination by biopsy shows a 
marked increase of the interpapillary buds in width and in height, 
with a very moderate cellular infiltration in the upper portion of the 
cutis. 

B. Deep Type or Cancroid Epithelioma. — This is the penetrating, 
infective, malignant form of epithelioma of the skin and the mucous 
membranes with a Malpighian lining. 



67 



TUMORS OF THE SKIN 



It develops especially at the orifices; on the lips, on the tongue 
(Fig. 71 ) and on the floor of the mouth, where it appears as a com- 
plication of leukoplakia, it is known as smokers' cancer; it is not 
uncommon at the amis and on the penis, but may occur anywhere, 
notably on scar tissue and on lupus vulgaris. 

When cancroid does not result from the malignant evolution of a 
papillary epithelioma, but originates in healthy skin, it is at first 
a grayish tubercle covered with a scale or a small crust. Under the 



. 




Fig. 192. — Horny lobular epithelioma, spinocellular epithelioma, or cancroid, 
developing on leukoplakia of the tongue. A, leukoplakia; B, raised border; C, 
erosion; D, lobulated masses; E, epidermic pearl; F, bloodvessel and plasma-cell 
infiltration; G, nerve; H, muscle tissue. X 38. 



influence of scratching or traumatisms, it increases in extent and in 
depth; its crest becomes reddened and ulcerated. Promptly a 
tumor forms, the size of a cherry-pit or a hazel-nut, hard, imbedded 
in the skin as well as protuberant. Its borders are raised and swollen 
and usually more or less hyperkeratotic. On the central area appears 
first an erosion, then a perpendicular ulceration, which is irregular, 
fissured, grayish and bleeds easily. 

Yellowish granules or filaments, known as "pearls" composed of 
horny cells and epidermic globules, may be visible and can some- 



EPITHELIAL TUMORS 679 

times be squeezed out. There may be pain on pressure and move- 
ment. The glands rapidly become enlarged. I have described 
elsewhere how this cancer develops on leukoplasic mucous mem- 
branes (p. 221). 

Histologically, the classical structure of lobulated horny pavement- 
cell epithelioma is seen (Fig. 192). The large cylinders which pene- 
trate into the depth of the tissues, where they form an irregular 
lobulated network with large meshes, are apparently derived from 
interpapillary buds or from pilo-sebaceous follicles. They almost 
invariably enclose collections of lamellar cells, concentrically 
arranged after the manner of an onion, known as epidermic pearls; 
more or less numerous dyskeratotic cells (p. 230) are regularly 
demonstrable. The stroma has a variable structure, but is rather 
scanty as a rule. At the circumference, plasmocytes are abundantly 
present. Neoplastic strands having the same structure as the original 
tumor may be found in the lymph channels. 

The tumor ultimately increases in depth, the ulcer becomes 
gangrenous, the infected cancerous glands may open externally. 
Death occurs in marasmus or as the result of hemorrhage. 
Generalization in the viscera is rare. 

The calcified epithelioma of Malherbe is a rare and very peculiar 
variety of spinocellular epithelioma in which the epithelial lobes 
undergo a total infiltration with lime-salts. It develops as a rule 
at the expense of old sebaceous cysts, wens or dermoid cysts and 
consists of masses of stony hardness which grow very slowly. Unless 
it undergoes transformation into ordinary cancroid, it follows a 
benign course. 

2. Tubular or Baso-cellular Epitheliomata. — In this group the neo- 
plastic masses assume a very variable arrangement, as narrow 
irregularly branching strands, in tubules, in leaf-like lobules with 
tapering processes, or as a network, etc. (Fig. 193) ; their continuity 
with the covering epidermis or with the pilo-sebaceous follicles is 
often demonstrable. In the center of these masses, small foci of 
mucous or colloid degeneration are sometimes seen which must not 
be mistaken for epidermic pearls. The neoplasm is composed 
exclusively of small oval or spindle-shaped epithelial cells, taking a 
deep stain, with few or no connecting filaments; briefly, presenting 
the appearance of the basal cells of the epidermis. The stroma is 
variable, often fibrous and sometimes mucous or embryonic. 

This kind of epithelioma is common in all persons of advanced 
years and in the aged, especially in connection with senile keratosis. 
Its seat of election is on the upper two-thirds of the face, where 
four-fifths of all epitheliomas are tubular; it is also encountered, 
although more rarely, on the lips, the tongue, in the pharynx, on the 
chest, the genital organs, etc. 



6S0 TUMORS OF THE SKIN 

The onset is usually in the form of an insignificant papule, which 
originates in healthy skin or on a patch of senile keratosis; there is 
a smooth, yellowish or grayish, pearly elevation, firm to the touch, 
the size of a pin-head or a lentil. It may resemble a Hat wart, a 
cellular nevus, a sebaceous or sudoriparous adenoma. A vague 
tingling sensation causes scratching; the papule becomes excoriated 
and covered with a constantly renewed crust or it may remain 
ulcerated. Its growth is very slow for a few months or even for 
several years, until quite suddenly it becomes more rapid. 



Fig. 193. — Tubular epithelioma (baso-cellular) of the cheek, with the clinical 
features of flat cicatricial epithelioma. Note the branched epithelial strands, made 
up of basal cells; their continuity with the surface epidermis and with a bud tra- 
versed by a sweat-channel ; the erosion covered with a crust on the right side in the 
illustration; on the lefl part of a mass which encloses a focus of mucoid degeneration. 
The neoplasm, which causesno protuberance, occupies the entire cutis down to the 
level of t he sudoriparous glomeruli and the vessels of the subcutaneous plexus. X 38. 

Although very readily curable in its incipient stages, by man}' 
kinds of treatment, this form of skin cancer nevertheless possesses 
extreme malignancy; it may become mutilating and incurable 
when it remains unrecognized, when intervention comes too late 
or the treatment is inappropriate. Its malignancy is purely local, 
however, glandular enlargement and metastases being invariably 
absent. 



EPITHELIAL TUMORS 



681 



Although constituting a single histological and nosological species, 
basocellular epithelioma tends to take an extremely variably course, 
so that it presents itself clinically under a highly variegated aspect, 
as tubercles surrounding a cicatrix, as an eroded surface, an ulcer 
or a tumor; these configurations may moreover coexist or follow 
one another. The following types may be described. 

(a) Flat cicatricial epithelioma while spreading becomes depressed 
at its center, which undergoes sclerotic atrophy. After a certain, 
sometimes very protracted length of time, it presents the appear- 
ance of a rounded or rather irregular cicatricial patch, bordered by 
a seam or chaplet of small grayish, scaly or smooth, more or less 
translucid elevations, owing to which it is also known as pearly 
epithelioma. Not infrequently, rather shallow, flat or granulating, 
slightly bleeding ulcerations form on the borders and gradually 
invade the vicinity (Fig. 194). The ulcer, bordered or not with 
pearly granules, often heals on one side while it extends on the other, 




Fig. 194. — Cicatricial flat epithelioma of the temple. Behind, on the side of the 
scalp and ear, a cicatricial surface is seen, interspersed and bordered with pearly- 
elevations; in front, on the side of the eye, there is a serpiginous ulceration. 



destroying the eyelids, the eyeball, the cartilages of the nose and 
even the bones; it gradually causes enormous and frightful muti- 
lations. I have observed cases which had lasted for twenty and 
thirty years. The tendency to recurrences, after an apparent cure, 
is extremely pronounced. 

(b) Pagetoid epithelioma is far from common, but important to 
know on account of the diagnostic errors to which it is subject; it 
presents a pinkish surface, distinctly circumscribed by rounded 
borders marked by a filiform margin, its area being spattered with 
small scales and crusts, resting upon an atrophic cutis. Its growth 
is extremely slow. I have observed it only on the face and on the 
back of aged individuals. It might be confused with senile keratosis, 
lupus erythematodes, psoriasis and especially with Paget's disease, 
or with the atrophic spots of Bowen's disease. Biopsy reveals 
more or less widely separated proliferations of basocellular epithe- 
lioma. 



G82 TUMORS OF THE SKIN 

(c) Rodent ulcer — or ulcus rodens — is characterized by a shallow 
and serpiginous ulceration, with a slightly indurated base, without a 
pearly elevation and a very slow course. Only very fine epithelio- 
matous tubules are seen in histological sections. 

ill) Epithelioma terebrans may be the outcome of one of the 
preceding varieties or it may set in primarily; the newformation 
and ulceration advance in depth rather than superficially; craters 
and often very deep oozing cavities appear, with a red granular 
surface, surrounded by a limited induration (Fig. 95). Although 
very destructive, mutilating and painful, this form likewise possesses 
a merely local malignancy; the glands generally remain intact as 
well as the general health. Many months and years may pass before 
the patient succumbs to hemorrhage or complications of one kind 
or another. 

(e) Proliferative tubular epithelioma, which is less common, gives 
rise on the contrary to a genuine tumor, in the form of an eroded and 
puckered macaroon-shaped elevation, or a protuberance the size of 
a pea, a hazel-nut, or rarely a large chestnut, sometimes peduncu- 
lated, of firm consistence, with an ulcerated and bleeding or crusted 
surface. This proliferation is sometimes seen to develop rather 
rapidly at some point of a slowly growing flat epithelioma. 

(/) Cylindroma of Billroth and Malassez, is really an atypical 
variety of the preceding form in which the stroma undergoes a 
mucous and hyaline degeneration; there is a formation of trans- 
lucid cylinders and clear ovoid proliferations which invade and 
push back the epithelial masses, resulting in peculiar histological 
appearances which have been variably interpreted, as shown by the 
numerous denominations of these tumors, such as siphonoma, 
endothelioma, plexiform sarcoma, angiosarcoma, etc. Cylindro- 
matous tumors are situated especially on the scalp, in the middle of 
the face, or in the buccal cavity; they are sometimes voluminous 
often multiple and rarely undergo ulceration. Their prognosis is 
the same as that of the other tubular epitheliomata. 

3. Nevo-cellular Epitheliomas or Nevo-carcinomata. — From the 
purely histological point of view, the cellular nevi themselves are 
benign nevo-cellular epitheliomas. 

These nevi, whether pigmented or not, verrucous or smooth, 
hairy or glabrous, are sometimes the starting-point of malignant 
tumors in adult and aged individuals; it has seemed to me that the 
face and the [heels and] plantar region of the feet are the two 
elective foci of this transformation. 

The tumor then is seen to enlarge in size and becomes painful; 
its circumference is reddened or becomes the seat of a melanotic 
pigmentation. Early and more or less rapidly invasive ulceration 
follows. Similar small tumors promptly begin to multiply in the 



EPITHELIAL TUMORS 683 

vicinity, then at a distance. In case the primary neoplasm was 
pigmented, generalization takes place by the appearance either of 
numerous secondary pigmented or non-pigmented tumors or of 
extensive localized or metastatic pigmentations, or of a generalized 
melanosis. The glands are promptly involved in this form, which 
often possesses great malignancy; metastases in the viscera, notably 
in the liver and lungs, is of common occurrence. 

The histological structure of these malignant tumors derived 
from nevi is peculiar (Fig. 195). 




It A. 



Fig. 195. — Histology of a pigmentary nevus (lentigo) and of the incipient nevo- 
carcinoma. Section from the border of the tumor, c. n. d., nevus cells, pig- 
mented or clear, in the cutis; c. n. e., pigmented nevus cells in the intra-epidermic 
tissue ; p, infiltration of plasma cells at the circumference of the tumor ; x, transition 
zone between the nevus and the nevo-carcinoma; n. c, tissue of the nevo-carcinoma 
of sarcomatous appearance; k, portion of an epidermic cyst which was contained in 
the nevus. X 57. 

Their constituents are globular or spindle-shaped, sometimes 
pigmented, arranged in compact masses, in imperfectly outlined 
strands or in alveoli; sometimes the appearance is entirely that of a 
sarcoma. 

For a long time such cases were interpreted as sarcomatous tumors 
and designated as melanotic sarcoma or melano-sarcoma. The name 
of nevo-carcinoma, proposed by Unna, who showed the epithelial 
origin of nevus cells and consequently of the neoplasms derived 
from them, is much better justified (see my paper on nevo-carcinoma, 
in Bulletin de V Assoc, f rang, du cancer, November, 1913). 

4. Secondary Carcinoma.— Metastatic epitheliomas are also met 
with in the skin, although but rarely, derived from operated or 



084 TUMORS OF THE SKIN 

non-operated cancers of the breast, or from internal cancers, as 
the result of neoplastic embolisms in the vessels. 

They are characterized by hard, pinkish, purplish or brownish 
elevations, the size of a pin-head to that of a hazel-nut; solitary at 
first, they gradually become confluent in irregular, mammillated 
surfaces (Velpeau's cancer en cuirasse). They are apt to ulcerate, 
proliferate and become fungoid. Sometimes an extensive patch or 
surface of scirrhus cancerous lymphangitis develops, which may 
resemble a patch of scleroderma. 

The histological characteristic of secondary carcinoma of the 
skin is that the neoplastic masses, made up of cells suggesting the 
primary tumor cells, are without connection with the surface or 
folliculo-glandular epidermis; they are arranged in branching tracts 
following the vascular and lymphatic channels; later on, alveoli 
are hollowed out. The dermic stroma presents at the onset prac- 
tically no indication of any reaction, but subsequently becomes 
sclerotic and retracted. 

Etiology and Pathogenesis of the Epitheliomata. — We know that 
cutaneous epitheliomas practically never develop until after the age 
of forty years and more frequently in males; when they occur in 
more youthful patients these will be found to have suffered as a 
rule from a precancerous affection. The part played by heredity 
is doubtful. 

The cause of the facial localization of the vast majority of epithe- 
liomata of the skin is not known; undoubtedly it is to a considerable 
extent because this region is the seat of election of senile degener- 
ation and leukoplakia; because it is particularly exposed to trauma- 
tisms, to inoculations of infectious germs, to the influence of atmos- 
pheric factors and especially of light, which seems to exert a 
favoring action [and possibly because the complicated planes of 
embryonic growth in the face afford a ready opportunity for the 
misplacement of epithelial cells]. 

The direct cause of epithelioma and cancerous tumors in general 
still remains unknown. 

The parasitic or exogenic theory, although very tempting at first 
sight, rests on no reliable basis. None of the hitherto described 
cancer parasites have withstood criticism. The coccidia which were 
supposed to have been discovered, turned out to be merely forms of 
cellular degeneration and dyskeratosis. We know that there exists 
in mice a form of contagious cancer, which is inoculable and can 
be indefinitely transplanted into animals of the same species, certain 
breeds of mice being predisposed to it; but the causative agent has 
never been isolated. There is nothing to justify the statement that 
human cancers are of infectious origin. Borrel reported in small 
epitheliomas of the face the usual presence of a demodex, which he 
believes to be the possible carrier of unknown pathog nic germs (?) 



EPITHELIAL TUMORS 



685 



Opposed to this interpretation are the cellular or endogenic 
theories, which assume aberrant embryonic germs and cellular 
heterotopia, with Cohnheim and Ribbert, or a loss of balance of the 
tissue constituents, or their abnormal fertilization, according to 
Hallion, etc. 

It must be admitted that the conception of precancerous states 
is rather an argument against the parasitic theory. Perhaps, epi- 
thelioma is merely the outcome of various processes, sometimes 
of teratological or dystrophic character; in other cases of ordinary 
inflammatory or even specific character. 




-Multiple epitheliomatosis of the face on senile keratosis, 
in the St. Louis Hospital, Paris. 



After a cast 



Precancerous Affections. — This designation is applied to patho- 
logical conditions which are so frequently the origin of cancers that 
this coincidence cannot be the effect of a mere accident. 

These affections are of various kinds and have been described in 
the chapter to which they belong. I shall therefore restrict myself 
in this paragraph to a general summary. 



686 TUMORS OF THE SKIN 

1. Xevi are malformations which lead to nevo-carcinoma. 

2. Various dystrophies are precancerous. 

The term of senile multiple epitheliomatosis (Pig. 196) serves to 
designate a very common syndrome consisting of the simultaneous 
or successive development of several epitheliomas at the site of 
senile keratoses (p. 209) and on a soil of senile degeneration of the 
skin. These epitheliomas are, as a rule, of tubular type, sometimes 
papillary or rarely mixed. Presenile dystrophy is followed by similar 
sequelae (p. 358). 

Xeroderma pigmentosum (p. 355) and up to a certain point the 
chronic radiodermatitides (p. 454) lead to an analogous picture; in 
the latter case, the epitheliomas as a rule are horny and papillary, 
later on cancroid. 

Arsenical cancer is simply a progressive and imperceptible trans- 
formation of verrucous arsenical keratoses (p. 213) into multiple 
epitheliomas, usually of a horny papillary type. 

3. Leukoplakia is entitled to special mention among the pre- 
cancerous affections, as it is the customary although not constant 
substratum of the lobulated epitheliomas of the mouth, the genital 
regions and the anus (p. 221). 

4. Epitheliomas of various types likewise develop, although much 
less commonly, on very different dermatoses, among which must 
be quoted: lupus vulgaris; cicatrices of any origin, but especially 
the old cicatrices of burns; the occupational dermatosis of chimney- 
sweeps, workers with tar and paraffin, coal-heavers; dermoid cysts 
and wens; ulcers and fistulas, obstinate psoriasis, lupus erythema- 
todes, etc. 

5. Among the dyskeratoses (p. 230), there are two which evidently 
represent precancerous affections: In Paget' s disease, the termina- 
tion in cancer is the rule, sometimes after a very long time, it must 
be admitted. In Bourn 's disease half of the known cases (three of 
the six cases published by Bowen and by myself) have led to can- 
cerous transformation. 

Diagnosis of the Epitheliomas. — The clinical forms are too varied 
to admit of completeness in this connection. At the onset, the 
epitheliomas must be distinguished from warts, nevi, etc. Cancroid 
sometimes resembles syphilitic chancre, or the tuberculo-ulcerative 
tertiary syphilides, or even tuberculous ulcer. Its neoplastic char- 
acter must be kept in mind; it is an ulcerated tumor, not an ulcera- 
tion with an indurated base. Flat cicatricial epithelioma is really 
easily distinguished from the eczematides, from lupus erythema- 
todes, from tuberculosis verrucosa; more commonly, the question of 
a tubercular syphilide may arise; but the principal difficulty which 
occurs in this connection is to decide whether or not a given spot of 
keratosis is already epitheliomatous. 



EPITHELIAL TUMORS 687 

Under all circumstances, I here repeat the definite and absolute 
rule which I have previously formulated, to the effect that when 
there is the least suspicion of epithelioma, recourse should be 
had to biopsy for the certainty which this method alone can supply, 
thereby permitting the timely institution of appropriate treatment 
(c/.,p.222). < 

[The American Society for the Control of Cancer has formulated 
the rule never to cut into a suspected growth without immediately 
sealing the cut surfaces by means of the actual cautery; to employ 
frozen sections for making an immediate diagnosis to be followed by 
radical operation at the same sitting, if indicated; and under no 
circumstances to allow more than twenty-four hours to elapse 
between the biopsy and the operation if the diagnosis is cancer. The 
risk of dissemination in cutaneous cancers is, however, very small.] 

Prognosis and Treatment. — Although the prognosis depends essen- 
tially upon the anatomo-clinical type, it is no less true that every 
epithelioma, no matter what its kind, should be completely removed 
or entirely destroyed. Internal treatment, arsenic, mercury, etc., is 
a waste of valuable time; iodide medication is decidedly harmful. 
Local intervention is what is required. The different forms of epi- 
theliomata, however, are not amenable to the same methods. 

Spino-cellular Epithelioma. — Papillary epithelioma must be treated 
by surgical removal, which is easy and provides rapid, reliable 
results. 

Cancroids demand the earliest possible and very wide surgical 
excision ; as a rule, the corresponding glands must be removed at the 
same time. Radiotherapy is not applicable to lobulated epithe- 
liomata and is certainly harmful in these cases. The few cured cases 
of lobulated epithelioma through the .T-rays or radium which have 
been reported, leave some doubt in the mind for lack of sufficient 
histological demonstration of the spino-cellular character of the 
tumor. On the contrary, I have repeatedly noted the occurrence 
of frightful aggravations under the action of this treatment. In 
the case of absolutely inoperable tumors, however, radiotherapy 
or radium may be utilized for the relief of the pains. Technical 
improvements of radium therapy and radiotherapy have on several 
occasions been promised, which would guarantee reliable cures even 
of spino-cellular epitheliomas; this progress may indeed be hoped 
for, but for the present a skeptic attitude is justified. 

Baso-cellular Epithelioma. — Flat cicatricial epithelioma and rodent 
ulcer are the triumphs of radiotherapy; innumerable cases have thus 
been permanently cured, with excellent esthetic results. Preference 
should be accorded to the method of massive doses and filtration 
through aluminum if necessary, to be repeated, provided the toler- 
ance of the skin permits (p. 453); the treatment should aim in a 



CSS TUMORS OF THE SKIN 

genera] way at keeping the tumor saturated with radiations until 
after an apparent cure lias been obtained. Should relapses occur, 
they will yield to renewed treatment. 

In proliferative tubular epithelioma, it is advisable first to excise 
the larger portion of the tumor, in order to reduce as far as possible 
the work to be accomplished by the radiations. 

A'-rays and radium institutes are now so numerous in all countries 
that recourse to them can almost invariably be had. It is useful 
to know, however, that baso-cellular epithelioma can be cured by 
other procedures. Surgical operation is not the best, for in the 
tubular forms it is necessary to pass rather considerably beyond 
the borders and the floor of the neoplasm, which leads to deplorable 
mutilations; in case of a recurrence, the additional operations will 
involve still greater difficulties. Flat epithelioma can be treated 
with the curette followed by applications of potassium chlorate, or 
by thermo-cauterization, or by any one of a large number of caustic 
agents. 

The most convenient and most desirable caustic, which has 
yielded the largest number of durable and good esthetic results in 
my experience, is arsenious acid, employed approximately according 
to the procedure of Czerny and Trunecek. After the epidermised 
surfaces have been scraped, or freshened or burned with the galvano- 
cautery, they are painted with a brush dipped in a supersaturated 
solution of arsenic (arsenious acid, 1 part; water and 90 per cent, 
alcohol, a a 50 parts); they are then left to dry and are covered with 
a pledget of cotton. At the end of five to eight days, the crust should 
be removed; if the subjacent surface is white, it is practically certain 
that the entire neoplasm has been destroyed; if it is mottled with 
gray and red, another series of cauterizations should be applied until 
a perfect result is obtained. This progressive plan of operating 
provides great security and spares the healthy tissues to the greatest 
possible degree; the pain is rarely very severe and does not last 
long. 

[Many dermatologists prefer the acid nitrate of mercury to any 
other chemical caustic. The tumor is vigorously curetted, the 
bleeding checked by compression for a few minutes and then the 
full strength Liq. hydrarg. nitratis is thoroughly applied by means 
of a cotton swab for several minutes. The surface is then covered 
with a thick layer of powdered sod. bicarb, firmly pressed down. 
Xo other dressing need be applied. In ten to fifteen days the crust 
is shed leaving a clean granulating surface which epidermises with 
surprising rapidity. The cosmetic result is excellent. | 

Other Epitheliomas. — The cylindromas are treated with the 
curette, with the bistoury, or with arsenious acid; recurrences are 
uncommon. 



VASCULAR AND CONNECTIVE-TISSUE TUMORS 689 

New-carcinoma has a gloomy prognosis, on account of its tendency 
to generalization. It is of the utmost importance to intervene early 
before dissemination has occurred. Electrolysis constitutes the 
treatment of choice; it sometimes yields unhoped-for results. I am 
in the habit of inserting the needle its full length underneath the neo- 
plasm, at numerous points from 4 to 5 mm. apart and allowing a 
current of 3 to 6 milliamperes to pass for two or three minutes, 
using the negative pole. Surgical operation is without advantage. 

In secondary carcinomas, the prognosis depends much more 
upon the principal tumor and its glandular and visceral generaliza- 
tion than upon the cutaneous localization. The latter often yield 
remarkably well to radiotherapy. 

Summarizing, it may be stated that in order to treat cutaneous 
epithelioma to advantage, it is of importance to make an early and 
accurate diagnosis, not only of the nature, but of the kind of tumor. 
For this purpose, examination of tissue by biopsy will [often be 
indispensable. The treatment must then be adapted to the type of 
the neoplasm, to its extent and its depth, as well as to its seat and 
to the general condition of the patient. 

VASCULAR AND CONNECTIVE-TISSUE TUMORS. 

This class comprises very different neoplasms, all of which how- 
ever originate in the last analysis from tissues derived from that 
portion of the middle embryonic layer known as the mesenchyma. 
Among these tumors, some have approximately the structure of 
normal tissues, as in the case of fibroma, lipoma, myoma, angioma, 
etc. The constitution of others is such as to result apparently 
from a local oversupply of elaborated material, perhaps not 
foreign in quality to the normal organism, but undoubtedly so in 
quantity: to this order belong xanthoma, urticaria pigmentosa 
and the tophi of gout, which may be considered as retention 
tumors. Finally, in a third group, a structure is found suggestive of 
embryonic or inflammatory tissues; in such cases the course may 
be benign, as in botryomycoma, or, on the contrary, of extreme 
malignancy, as in the sarcoma. 

Fibroma. — Aside from fibroma molluscum which has been men- 
tioned among the nevi, there occur hard dermic or hypodermic 
fibromata, of very variable size, which may appear at any age; 
they are sometimes multiple and as a rule do not recur after removal. 
They are formed by a dense fibrous tissue without elastic network 
and may undergo fatty, xanthomatous or mucous degeneration, 
or calcification. Some of these tumors seemed to me to be sarcoids 
which had become fibrous; others might be regarded as subcutaneous 
keloids. 
44 



090 



TUMORS OF THE SKIK 



Keloids (xyfy = the claw of a crab) are histologically simply 

hard fibroma s; but they acquire a very special interest through 
their etiology, their appearance and their clinical course. 

Keloids are preferably observed in children and in youthful 
individuals; their seat of election is on the chest, on the neck and 
on the ears; they are less common on the limbs. [Negroes are 
especially prone to keloid.] 

A distinction has been erroneously attempted between cicatricial 
keloids and spontaneous keloids, which represent a single variety 
of tumors. A keloid may develop upon a cicatrix following a burn 
(Fig. 197), lupus, chancroid, etc., with the result that the scar 
assumes a more than hypertrophied and deformed appearance 
(p. 336); or it may follow a slight traumatism, excoriation, vac- 
cination, perforation of the ear-lobe, the bite of a leech, or the 




Keloid df the neck, on a cicatrix following a burn. 



application of a blister, iodine tincture, etc. ; it may also appear as a 
sequel of furuncles, syphilides, or acne pustules. In the last-named 
case, the post-acneic keloids scattered over the thorax and the face, 
have nothing in common with the affection known as keloid acne 
of the nape of the neck (p. 391 ). The relative rarity of keloids as 
sequelpe of wounds in the late war is noteworthy. 

Whatever its starting-point, a keloid begins as a circumscribed, 
intradermic prominent induration which enlarges in a few weeks or 
months. It becomes a very hard tumor, with a smooth, level or 
indented, pinkish or white surface with steep or gently sloping 
borders, of globular, oval, or frequently elongated shape; it often 
exceeds the limits of the original lesion and may attain the size of 
an egg or form a band or elevation thicker than the finger. Xot 
uncommonly, the borders or the extremities of keloids present 



VASCULAR AND CONNECTIVE-TISSUE TUMORS 691 

fibrous radiations and sometimes bifurcated strands, which suggested 
the name given to these tumors by Alibert. There may be absolute 
freedom from pain, or the patient may complain of unpleasant 
tingling sensations. 

After having increased in size and extent for a few months or 
years, a keloid may remain stationary or may undergo spontaneous 
retrogression. Surgical removal is followed by recurrence in case 
of recent tumors whose development has not been completely 
arrested. These recurrences are common, not in the entire extent 
of the surgical cicatrix, but in a portion of the scar, in some of the 
suture points, but not in all. Moreover, in case of acne for instance, 
which becomes keloid, some but not all of the pustules undergo this 
development. From these facts it may be concluded, as I have 
pointed out, that the appearance of keloids is not connected with a 
peculiarity of the soil, with a scrofulous or fibroplastic (?) diathesis, 
as has been claimed, but with a local infection. I am inclined to 
believe, with T. C. Fox, J. N. Hyde and others, that this infection 
is of tuberculous character, at any rate in most cases, so that the 
keloids or at least certain keloids are tuberculides or attentuated 
tuberculoses. Their structure is that of a very dense fibroma, with 
mature connective-tissue bundles rich in mast cells (Mantegazza, 
1897). 

In the treatment of keloids, a host of medicinal agents has 
been utilized — iodine, arsenic, cod-liver oil, salicylates, thiosina- 
mine and fibrolysine; locally, plasters, local douches, scarifica- 
tion, interstitial injections of creosote oil and other substances, 
electrolysis, etc. I have mentioned the disadvantage of surgical 
removal, the risk of a larger recurrence with worse deformity. 
Radiotherapy is more to be recommended. A few sessions will 
procure considerable improvement; before pushing further, the 
vitality of the fibrous tissue must be aroused, for example, by 
negative electrolysis or by local injections, or more practically by 
deep interrupted scarifications; after which the .r-rays may be 
resumed and will be found to have acquired an increased activity. 
I have obtained numerous permanent results by means of this 
method. 

Lipoma. — The circumscribed lipomas belong to the domain of 
surgery. 

Multiple subcutaneous lipomas develop in certain individuals, in 
crops from a few to several thousands in number. Their structure 
is that of normal adipose tissue; their size varies from that of a pea 
to a small mandarin orange; their consistence is soft, lobulated 
and sometimes pseudo-fluctuating; their distribution is often more 
or less symmetrical. The differential diagnosis from neurofibroma- 
tosis must be made; this condition probably represents an analogous 



692 TUMORS OF THE SKIN 

nevic disease. Fibromas are sometimes partly lipomatous. Cer- 
tain so-called lipogenic angiomas have a tendency to undergo a 
transformation into lipoma. 

Myxoma. So-called pure myxoma, soft tumors composed of 
mucoid connective tissue, are probably partial elephantiasis, as in 
the case of tumor of the vulva shown in Fig. 116, in which the diag- 
nosis of myxoma had been made. These neoplasms are preferably 
situated on the genital organs and on the eyelids. Aside from these 
false myxomas, there also occur myxo-sarcomas or sarcomas in 
course of myxomatous degeneration. 

Myoma. — The dermatomyomas or cutaneous leiomyomas — 
which alone will be discussed in this place — have been classically 
described by E. Besnier. These tumors, composed of smooth 
muscle-fibers forming a network of interwoven bundles, are derived 
either from the erector muscles of the hair-follicles, or from the 
muscle cells of the vessels. Myomas are rare and are observed in 
women more often than in men. They may develop at any point, 
as disseminated or agminated rose-colored elevations, attaining the 
dimensions of a pea or at most a hazel-nut. They are frequently 
very tender on pressure and constitute the majority of what has 
been described as painful tubercles of the skin ; they become the seat 
of attacks of pain under the influence of local irritation or the action 
of cold. 

Calcareous Tumors. — In addition to true osteomas, which are 
exceptional, calcified fibromas, calcified epitheliomas, petrified wens 
and cysts, as well as phleboliths, the following are known: 

1. The petrous tumors of Poirier, which are calcified fat-lobules 
the size of a grain of wheat, occurring on the inner aspect of the tibia 
in aged individuals. 

2. Subcutaneous calcareous granulomas, which begin as a sort of 
cold abscess with granular or gravelly contents and may multiply 
until they lead to death with systemic symptoms. This affection, 
whose lesions closely suggest those of tuberculosis, is undoubtedly 
infectious. 

3. The subcutaneous calcareous concretions of scleroderma (p. 
350). 

Colloid Milium. — This very inappropriate term serves to desig- 
nate small, yellowish, translucid and painless tumors, the size of a pin- 
head to that of a pea, which may be found scattered or more or less 
grouped in the face, on the neck and the upper extremities of adults 
of either sex (p. 359). At first sight they resemble serous cysts; a 
sort of jelly can be squeezed out of them or they may be enucleated 
with the curette. Balzer has shown them to be made up of a colloid 
tissue; degeneration of the dermic tissue into elacine and collacine 
has been demonstrated. Milian, who recently published a case of 



VASCULAR AND CONNECTIVE-TISSUE TUMORS 693 

colloid milium (1917), interprets the condition as a limited prolifera- 
tion of bundles of subepidermic connective-tissue fibers, with 
hyaline degeneration. The foci stain yellow with van Giesen's 
stain and a dull blue with thionine. With some attention, it is 
possible to avoid confusion of colloid milium with hidrocystoma, 
hidradenoma, lupoma or sarcoid, as well as with senile colloid 
atrophy (p. 357) which, moreover, is spread out in patches and 
diffuse. The galvanocautery, carbonic acid snow or the curette may 
be utilized for the treatment. 

Angioma. — Hemangioma.- — The majority of angiomas are vas- 
cular nevi, the lesion consisting of hypertrophy with ectasis of the 
veins and, to a less degree, of the capillaries and the arterioles. 

According to their clinical aspect and the date of their appear- 
ance a distinction is made between several forms: 

(a) Flat angiomas or flat vascular nevi, the port-wine stain of 
popular parlance, are spots of very variable shape, outline and dimen- 
sions, punctiform or in very extensive patches. Their color varies 
at different times from pinkish to bright red or purple. They are 
especially common on the face and around the natural orifices. 
On the nape of the neck, at the border of the scalp, they are encoun- 
tered in nearly 10 per cent, of all persons. [In an examination of 
several hundred infants less than a week old, I found vascular nevi 
on the neck below the occipital protuberance in one-third of the 
cases. Most of these become invisible in the course of time.] They 
may be seen on the mucous membranes. In epileptics and in feeble- 
minded persons, patches of vascular nevi may be found on the 
entire body and on the limbs. [I have recorded a unique case 
occurring in an otherwise normal man in which the entire integu- 
ment was covered with vascular nevi of the average size of a dime, 
so closely placed as to form a kind of network. Histologically 
there was a deficiency of elastic tissue. Dermographism was present.] 
These angiomas are, as a rule, congenital. They are sometimes 
hypertrichotic. 

(b) Tuber ovs angiomas are primary or develop on the basis of 
the preceding variety. Sometimes they form merely a slightly 
marked prominence, reducible on pressure, distinctly circum- 
scribed or with diffuse borders; in other cases, they are voluminous 
and may cause more or less deformity of the lips, the nose, the eye- 
lids, the ears or the tongue, up to lending them a monstrous appear- 
ance. The surface is bright red and granular or dark blue and 
lobulated, according to the depth of the lesions. Those of the cheek 
and lips sometimes extend to their mucous surface. They often 
cease very accurately on the middle line. Aside from their dis- 
figuring appearance, these tumors may prove troublesome and 
after traumatism may bleed profusely. 



()!)4 TUMORS OF THE SKIS 

The prognosis and the treatment of these angiomas vary. Some 
of them have a natural tendency to a cure, through lipomatous 
transformation (lipogenic angioma) or sclerotic change; others 
simply persist; still others are progressive. In case of a newborn 
infant suffering from an angioma, its course should accordingly be 
determined before interfering. In the first two cases, delay is per- 
missible; in the presence of a progressive angioma, prompt measures 
are required. 

For a long time the only choice lay between the following pro- 
cedures: Compression, usually inefficient; actual cauterization or 
applications of caustic agents, which leave ugly cicatrices; surgical 
removal, the method of choice when the dimensions and the seat of 
the angioma permit; scarifications, of advantage in small flat nevi; 
vaccination, which is rarely applicable; and finally electrolysis. 
The last-named procedure, the details of which have been well 
described by Brocq, is preferably carried out with the positive pole 
and a current of 3 to 10 ma. for one to three minutes; the number 
of punctures and sessions is increased until a satisfactory result is 
obtained. [Ultraviolet light with compression often yields good 
results in the flat varieties.] 

At the present day radiotherapy is furthermore available, but is 
not always effective when a safe dosage is employed. Radium 
seems to me to possess a real superiority in this respect, especially 
in case of tuberous nevi of moderate depth and inconsiderable size ; 
but care must be taken to guard against radium dermatitis. Flat 
vascular nevi are advantageously treated with carbonic acid snow, 
which when skilfully handled leaves only slightly visible cicatrices. 
Large tuberous angiomas belong to the domain of surgery. 

(c) The progressive multiple angiomas constitute a clinical form 
not heretofore described; I have observed several instances on the 
face or on the extremities of young or adolescent individuals. They 
are represented by at first subcutaneous nodosities, of firm consist- 
ence, but reducible, which multiply and raise up the skin, giving it 
a slate-blue hue; later on the skin is invaded and becomes the seat 
of a purplish depressible growth, which bleeds readily. Ten or 
fifteen of these tumors, the size of buckshot to that of a large hazel- 
nut, may be seen strung out on the sole of the foot and on the leg, 
or scattered over the face. The course lasts from six months to two 
or three years; ultimately, some of these angiomata spread over 
very extensive surfaces, with diffuse borders, while others remain 
stationary or undergo spontaneous retrogression. The differential 
diagnosis may prove difficult from the pigmentary sarcomatosis of 
Kaposi, from telangiectatic sarcoma, or from nevo-careinoma, but 
is established on biopsy, which shows simple cavernous angioma. 
It is of great importance to treat these angiomata while they are 
still small with electrolytic punctures, which promptly cure them. 



VASCULAR and connective-tissue tumors 



695 



(d) Stellate angioma is a very common nevus, which often appears 
late, about the time of puberty or still later. It consists of a red 
and prominent central point, from which radiate telangiectatic 
arborizations resembling spiders' feet (Fig. 198). It is easily con- 
trolled by the galvano-cautery heated to a dull red, or better by an 
electrolytic puncture. 







Fig. 198. — Stellate angioma or vascular nevus araneus. 



(e) Senile angiomas [in French "pointes rubis," ruby spots] are 
punctiform or at most lenticular, slightly prominent angiomas 
which develop with great frequency and in large numbers on the 
trunk and the limbs of individuals past forty years of age. They 
have been credited with the property of indicating a visceral cancer, 
but this has been shown to be erroneous. They may be considered 
as delayed vascular nevi. 

(/) The angiokeratoma of Mibelli is observed on the extremities 
of young individuals with acro-asphyxia, suffering from frost-bite, 
glandular tuberculosis, etc.; so that Leredde classifies it with the 
tuberculides. The lesions present the appearance of small spots 
of a bright red color, grouped or agminated, situated especially on 
the dorsal aspect of the hands and fingers, rarely elsewhere; their 
surface generally becomes hyperkeratotic and verrucous. After a 
few months these angiokeratomas may disappear spontaneously. 
They may be treated like the senile angiomas with the galvano- 
cautery. 

In addition to the Mibelli type, hyperkeratoses have been de- 
scribed as occurring on vascular angiomas and telangiectases of all 
kinds, notably on the scrotum where they are not very uncommon; 
I have observed several cases even upon the tongue. 

Lymphangioma.— These very rare tumors occur as the result of 
a newformation of lymph vessels with dilatation. They are referable 
to a primary malformation and must be considered as lymphatic 



G9G TUMORS OF THE SKIN 

vascular nevi. A confusion with lymphatic varicosities has caused 
much trouble and, as a matter of fact, the distinction between the 
two groups is not always easy. In my opinion, these differences 
may be explained as follows: 

Lymphatic varicosities, or lymphangiectases, are acquired dilata- 
tions of the lymph channels of the skin and mucous membranes. 
They are generally a complication of, or substitute for, elephantiasis 
(Chapter XVIII) and seem to be caused by an obstruction in a 
lymph vessel or gland as the result of tuberculosis, syphilis, filariasis 
and especially of recurrent erysipelas. 

Lymphatic varicosities are observed in the mouth, on the mucosa 
of the lower lip, the cheeks and the tongue, in the form of clear, 
translucid, beaded or acuminate pseudo-vesicles, of variable number 
and size; they sometimes become white and opaque; or sometimes 
red or black through penetration of blood into their cavity. They 
slightly resemble herpetic vesicles, but are reducible on pressure; 
moreover, when pricked with a pipette, they furnish an almost 
unlimited quantity of a clear fluid which is lymph. The subjacent 
tissues are in a state of chronic edema. Lymphangiectases are 
frequently associated with elephantiasis of a limb. 

Accordingly, lymphatic varicosities may present themselves 
without tumors, as acquired lesions secondary to a process causing 
lymph stasis. On the other hand, they will be shown to form also 
an integral part of the lymphangiomas. 

Circumscribed lymphangiomas are congenital tumors or they 
may appear in early childhood. They consist of rose-colored 
elevations, more or less firm to the touch, conglomerated in patches 
and covered with lymphatic varicosities. The latter are very com- 
monly associated with dilated bloodvessels, namely, with heman- 
gioma, and this combination has been interpreted in a variety of 
ways [and gives to the patches a mottled polychromatic appearance]. 

Lymphangiomas are preferably situated on the neck and at the 
root of the limbs; I have observed them also on the flank, in the 
parotid region, on the knee, etc. They are progressive, but slow and 
painless, so that the patients put off seeking advice. As a result of 
interstitial growth, they may give rise to monstrous deformities. 
The presence of lymphatic varicosities at given points of their surface 
constitutes their essential distinctive feature. 

Lymphangioma may be treated by extirpation, which is rarely 
followed by recurrence when complete, or with the galvano-cautery, 
or by electrolysis; the latter is also suitable for the treatment of 
simple lymphangiectases. Radiotherapy results in a well-marked 
but transitory improvement. 

Primary diffuse lymphangioma is identical with congenital ele- 
phantiasis (Chapter XVIII). 



VASCULAR AND CONNECTIVE-TISSUE TUMORS 697 

Xanthoma. —Under the name of Xanthoma (W. P. Smith) is 
designated the disease corresponding to Rayer's yellow patches of 
the eyelids; the vitiligoi'dea of Addison and Gull; the xanthelasma 
of E. Wilson, etc. 

Until the last few years, the nature of this disease appeared to be 
very mysterious; as it could not be considered as neoplastic, it was 
for a short time believed to be of infectious origin. Its affinities had 
been recognized on the one hand with diabetes or glycosuria, on the 
other with chronic icterus and diseases of the liver in general. The 
yellow cast of the skin and mucous membranes as a whole, which 
is noted in many cases of xanthoma, not necessarily accompanied 
by choluria, was distinguished from icterus and described as xantho- 
chromia; it has theoretically been referred to xanthomatous lesions 
of the biliary passages, which, however, have never been demon- 
strated. Cases of family or congenital xanthoma were known to 
occur. 

Recent contributions, for which we are indebted to Pinkus and 
Pick, but especially to Professor A. Chauffard with Grigaut and Guy 
Laroche, have shown xanthoma to be related to cholesterinemia. 
The fatty substance which is abundantly present in the lesions 
and characterizes them, is not an ordinary fat, that is, a fatty acid 
glycerine ether, but is a lipoid, a fatty acid cholesterin ester. The 
new teachings are accordingly as follows: 

Cholesterin, an integral constituent of all body tissues, exists 
normally in the blood serum in a ratio which, according to Grigaut, 
oscillates between 1.20 and 1.80 per thousand; it is derived to a 
small extent from the food but mainly from an internal secretion 
of various tissues and organs, among which the suprarenal capsules 
figure predominantly and secondarily the corpora lutea of the ovaries. 
It is eliminated through the bile, either in its natural state or per- 
haps in the form of cholalic acid. Its antihemolytic and antitoxic 
action has been definitely established. Cholesterinemia is increased 
during pregnancy and in the puerperal state as well as during men- 
struation; while lowered as a rule at the onset of infections, it is 
raised in convalescence. Its highest ratio is reached in the course 
of Bright's disease and especially in icteric conditions due to reten- 
tion; its relations with diabetes are not constant. 

The conclusion has thus been reached that when the cholesterin 
is insufficiently eliminated it accumulates in the skin (xanthoma) 
and in the mucous membranes, likewise in the walls of the arteries 
(atheroma). Xanthematous deposits have sometimes been found 
on the endocardium, on the peritoneum and even in ovarian cysts 
(Malassez and de Sinety). The lesions of xanthoma, being prin- 
cipally due to this deposit of cholesterin, may be considered up to a 
certain point as retention-tumors. 



69S 



TUMORS OF THE SKIN 



Clinically, xanthoma presents itself under four forms: 
A. Xanthoma plan nut of the eyelids, which has received the special 
name of xanthelasma, is the most common. It consists of straw 
yellow or dusky, distinctly outlined, sometimes slightly prominent 
spots which are located more or less symmetrically on the most 
internal portion of the eyelids (Fig. L99). Their seat, their extent 
and their color serve to distinguish them from the hidradenomas 
and the sebaceous adenomas of this region. Xanthelasma usually 
develops insidiously in adults and aged individuals, somewhat 
more frequently in women, as a solitary manifestation of xanthoma, 
often without apparent disturbance of the general health. But I 




199.— Xanthelasma of the eyelids 



have noted its rather abrupt onset in the course of hypertrophic 
cirrhosis with icterus. It sometimes becomes associated with one 
of the following forms: 

B. Eruptive xanthoma xanthoma tuberosum multiplex — is more 
uncommon; it may he met with at any age, even in young children 
(Plate IV). It consists of papular or tuberous elevations, having 
the dimensions of a pin-head to those of a large bean, of a golden 
yellow color with a pinkish areola, or it may be of a dark more or 
less purplish red; in the latter case, the yellow hue of the lesions 
can be demonstrated by means of vitropressure. Their consistence is 
sometimes soft, in other cases solid or even keloidal. The eruption 



PLATE IV 



m 






j 




./ # 






j 



i 



Eruptive Xanthoma, in a Child of Four Years. 



VASCULAR AND CONNECTIVE-TISSUE TUMORS 699' 

may be slow, progressive, appearing in successive crops; or it may 
be sudden, becoming established in less than a month ; occasionally, 
the yellow papules make their appearance upon persistent erythe- 
mato-urticarial spots. 

The lesions vary greatly in numbers in different cases and are 
sometimes pruritic or painful. They are somewhat symmetrically 
arranged, especially on the elbows, the knees, the shoulders, the 
buttocks, the finger-joints and the scalp. Xanthoma may be said 
to favor high places. This localization is perhaps referable to the 
fact that these regions are more exposed to blows and to friction, 
for yellow linear streaks are not infrequently observed at the same 
time on the flexion-folds of the palmar and plantar regions and the 
fingers, as well as xanthelasma of the eyelids; in other words, the 
xanthomatous infiltration preferably takes place at points where 
the skin is often folded or bruised; Chauffard observed a patient in 
whom every puncture for arsenic-injection became the center of a 
xanthomatous nodule. 

The lesions persist indefinitely, or they may become absorbed and 
disappear. There is no reason, however, to distinguish with [M. 
Morris] Robinson and Torok an acute, temporary or intermittent 
form, constituting diabetic or glycosuria xanthoma. [The glycosuric 
form is however clinically distinguished by the presence of a vivid 
red zone on the sides and surrounding the base of each nodule, an 
appearance extremely rare in the non-glycosuric form.] 

C. Congenital xanthoma, in tumors, manifests itself in the form 
of prominent, globular or conglomerated, sessile or pedunculated 
newformations of a yellow, dusky or purplish color, soft or fibrous 
and hard, which may attain the size of a mandarin orange or larger. 
They occupy the crest of the elbows (Fig. 200), the knees, the 
shoulders, sometimes still other regions. These tumors are present 
at the time of birth, or make their appearance in the course of the 
first months of life. 

D. Secondary xanthomatization has been seen in various tumors, 
notably in nevi. I was enabled to study a cutaneous fibroma which 
was histologically xanthomatous, as well as a xanthomatous rhab- 
domyoma of the tongue; Pollitzer observed one on the eyelids. 
This cholesterin infiltration of all kinds of neoplasms is very readily 
accounted for at present. 

It seems advisable in this connection to point out that pseudo- 
xanthoma elasticum (p. 358), the first reported cases of which were 
confused with xanthoma, is a cutaneous dystrophy of altogether 
different character. 

Pathological Anatomy. — The blood of xanthomatous patients is 
far from always being distinctly lipemic, with milky serum. The 
highest ratio of cholesterinemia noted by Chauffard (1910) in 
patients having xanthelasma is 1.90 per thousand; in multiple 



700 



TUMORS OP THE SKIN 



xanthoma the blood has been found to contain 6.0 or more of 
cholesterin per thousand. 

The histology of xanthoma shows that the lesions are made up by 
collections in the cutis of large connective-tissue cells of very special 
appearance, polyhedric or spindle-shaped, often arranged concen- 
trically around the vessels, frequently with a compressed central 
nucleus and a vacuolated foamy protoplasm; their vacuoles enclose 
fatty granules which will be discussed presently; these are the 
xanthelasmic cells of Chambard, now known as xanthomatous cells; 
in certain cases a considerable number of these are polynuclear and 
giant cells. The xanthomatous cells are arranged in nodules or in 
strands separated by bands of connective and elastic tissue. There 




Fig. 200. — Xanthoma in tumors, in a girl, aged nineteen years. Similar tumors 
existed on the other elbow and on both knees, with xanthelasma of the eyelids. 

sometimes seems to be a fibrous reaction which encloses the special 
constituents and gives to the whole a fibromatous consistence. The 
epidermis is normal or loaded with pigment. The fatty substance 
peculiar to xanthoma generally assumes the form of fine granules or 
round droplets, but sometimes also that of crystals in small rods or 
in hue needles united in clusters. It is for the most part contained 
in the xanthomatous cells, although some of it is also almost invari- 
ably found in the intercellular spaces. It is soluble in strong 
alcohol, in ether and essential oils; heat melts it, so that in order to 
see it, the fresh specimen must be fixed with chromates or better 
with osmic acid or Flemming's fluid, or with formol; or cut as 
fro/en sections and mounted in glycerine. It will be found that a 
considerable part of these granules stain poorly with osmic acid, 
take an orange red stain with Soudan III and, as was first observed 



VASCULAR AND CONNECTIVE-TISSUE TUMORS 701 



by Stoerk, present the phenomenon of double refraction with 
polarized light; this is therefore not ordinary glycerine-fat, but 
rather a cholesterine ether. Other granules are stained a deep black 
with osmic acid, are turned red by the Soudan reagent and remain 
dark when the prisms of the polariscope are crossed; these are 
ordinary fats. The two kinds of granules, which with Policard and 
Mangini I have usually found to exist together in xanthomas, are 
variably distributed in the lesions. Histologically the difference 
between a simple deposit or an active absorption of these substances 
by the perivascular connective-tissue cells cannot be determined. 

[In my opinion, xanthoma tuberosum multiplex, the eruptive disseminated 
form, and xanthoma planum or xanthelasma, the form that occurs on the 
eyelids, are two distinct diseases. My studies on this subject have been 
published in the New York Med. Jour., 1898, Jour. Cutan. Dis., 1910, xxviii, 
633, and, in collaboration with U. J. Wile, ibidem, 1912, xxx, 235. I present 
here the principal points of difference between the two diseases: 






1. Prominent, hard, round or lobulated 
tumors. 

2. Occurs at any period of life but pref- 
erably in early adult life and childhood. 

3. Development rapid, in a few weeks 
or months. 

4. Disappears after months or years, 
or undergoes fibrous changes and persists 
indefinitely. 

5. Extremely rare. 

6. Distribution general with the neigh- 
borhood of the large articulations as seat 
of predilection. (Under the tense epi- 
thelium of the palms the tumors may be 
spread out in stria? along the normal folds.) 

7. Histologically, xanthoma is an irrita- 
tive connective-tissue-cell hyperplasia, 
due to the presence of cholesterol fatty- 
acid esters derived from the blood. The 
process begins in the cells of the vascular 
adventitia, which take up the extruded 
fatty particles, increase in size and pro- 
liferate, sometimes becoming multinu- 
cleated. These cell masses in turn 
commonly act as stimulants to the pro- 
duction of fibroblasts, resulting, in old 
xanthomas, in the development of fibro- 
mas which have erroneously been inter- 
preted as the primary tumor, "xantho- 
fibroma." Xanthoma connotes a systemic 
disease, a disturbance of metabolism.] 



Xanthelasma. 

1. Flat, soft, indistinguishable on pal- 
pation, or if at all prominent, feels like a 
bag of fat. 

2. Practically unknown before middle 
age. 

3. Development slow, extending over 
years. 

4. Persists unchanged through life; 
never undergoes fibrosis. 

5. Quite common. 

6. Limited to face and neck, the region 
of voluntary cutaneous muscles. 



7. No signs of connective tissue or other 
inflammatory changes. It occurs only 
when there are striated muscle fibers in 
the skin, that is, the face and neck 
(platysma), but similar degenerations 
have been observed in the tongue, the 
uvula and in congenital myomata and are 
reproduced to some extent in the waxy 
degeneration of muscles after typhoid, 
etc. The so-called xanthoma cells of 
xanthelasma are cross-sections or frag- 
ments of muscle fibers of the orbicularis 
palpebrarum which have undergone a 
peculiar cholesterol fatty degeneration 
with proliferation of sarcolemma nuclei. 
Xantho-myoma does not occur ; so far from 
a tumor or increase of the muscle tissue 
there is, on the contrary, a disappearance 
of muscle fibers. In long-standing xanthe- 
lasma there is scarcely anything left of 
the original muscle in the areas affected. 
Xanthelasma is independent of any 
known general disorder. It belongs with 
the cutaneous degenerations.] 



702 TUMORS OF THE SKIN 

Treatment. — As a rule, xanthoma shows a tendency to persist 
and increase. The undesirable spots of xanthelasma and even the 
xanthomatous papules can be made to disappear, however, almost 
without cicatrices, by very careful cauterization with the galvano- 
cautery, heated to a dull red. The classical medication with tur- 
pentine in capsules, which has long been followed, seems advantage- 
ous. At the present day, however, the treatment must obviously 
be based upon the hypocholesterin diet, recommended by Chauft'ard, 
consisting of roasted and broiled meats, green vegetables, skimmed 
milk, fruits and sugar. 

Tophi of Gout. — If the modern interpretation of xanthoma is 
correct, this disease presents great analogies with gout. The uric 
acid which circulates in excess in the blood in the last-named 
dyscrasia, is deposited not only in the joints and the peri-articular 
tissues and sometimes in the viscera, but frequently also in the skin. 
The urates deposited in the cutis and the cellular tissue are known 
as tophi. According to Garrod and Charcot, who made a special 
study of the subject, tophi are found in nearly one-half of all gouty 
patients (lb times in 37 cases). 

Their seat of election is on the external ears, in the groove or on 
the sharp border of the helix, where these concretions, from one or 
two to about ten in number, constitute small tumors the size of a 
millet-seed to a pea. Their color is normal or purplish, with an 
opaque white hue shining through it. Tophi have occasionally 
been observed in various other regions; on the ala? or on the bridge 
of the nose, on the scalp, on the eyelids, etc. 

Their other common seat is in the vicinity of gouty joints, over 
the olecranon or the prepatellar bursa for example, or around the 
joints of the fingers and toes. These tophic concretions are sub- 
cutaneous or intradermic; at first small and multiple, they tend to 
become agglomerated and spread out. Soft at first, they subse- 
quently become extremely hard. 

Tophi make their appearance as a rule after attacks of gout, 
causing slight inconvenience and sometimes disappearing spon- 
taneously ; in other cases, abscesses develop, or still more frequently 
the skin becomes stretched, opens without suppuration and permits 
the escape of a chalky substance chiefly composed of sodium urate. 
Under the microscope it appears as circular crystals, soluble in hot 
water, which on treatment with acetic acid yield uric acid crystals; 
with nitric acid and ammonia, the murexide reaction is obtained. 

In contradistinction to lime concretions, urate concrements are 
transparent to the .r-rays. It has been suggested to treat them by 
means of lithium ionization. The simplest way to get rid of tophi 
on the ears is extirpation with the curette, under local anesthesia. 



VASCULAR AND CONNECTIVE-TISSUE TUMORS 



703 



Urticaria Pigmentosa.— The name given to this affection by 
Nettleship is not a good one, in so far as it leads to confusion with 
pigmented urticaria (Chapter II). 

Urticaria pigmentosa (xanthelasmoidea of T. C. Fox) is not a 
variety of urticaria, but a chronic skin disease which histologically 
is ranged with the retention tumors. 




-Urticaria pigmentosa in the 
resting state. 



Fig. 202. — The same urticaria pigmen- 
tosa in the urticarial state, after irrita- 
tion by energetic rubbing. 



It is characterized by spots or not very prominent elevations, from 
a pin-head to a fingernail in size, of a dusky or tawny color; these are 
distributed over the integument in variable number, from a dozen 
or so to several hundreds, situated especially on the trunk and on the 
limbs, but sometimes also on the head and the extremities. 

The pathognomonic sign of urticaria pigmentosa consists in the 
inherent property of these spots or elevations to become congested, 
swollen, firm and distinctly urticarial under the influence of active 
scratching or pressure with a blunt instrument (Figs. 201 and 202). 

This sign by itself alone would suffice to differentiate these lesions 
from those of lichen planus, psoriasis, syphilides or tuberculides,, or 
from simple macules which they sometimes closely resemble * 



70-4 TUMORS OF THE SKIN 

The usual teaching is to the effect that urticaria pigmentosa begins 
a short time after birth, rarely after the first year; that it disappears 
at the end of eight or ten years through progressive obliteration and 
would accordingly be very rare in adults. This is often correct. I 
have shown, however, before the French Dermatological Society 
in 1905, that this affection may last indefinitely; that its appear- 
ance may be noted at puberty or even at a mature age; that it is 
sometimes familial. The eruption in some cases is subject to con- 
gestive attacks with pruritus, spontaneous or in connection with 
sweating; in other cases, it remains sluggish and latent, so that its 
existence may be overlooked on superficial examination. The exist- 
ence of dermographism has been reported in these patients; this may 
be a mere coincidence and at all events is not common. 

The histology of the lesions shows in the cutis an abundant 
infiltration of mast-cells, staining a purplish red with polychrome 
blue; these cells are spindle-shaped, oval or polygonal when ac- 
cumulated in masses. Pigment is found in the basal layer of the 
epidermis and in the papillary body. 

The etiology is unknown. Cutaneous irritation, nervousness and 
emotional disturbances have been held responsible. It seems to 
me that auto-intoxications of digestive origin or certain disturb- 
ances of the hepatic function may play a role. Investigations 
aiming at the separation of the complex of hepatic insufficiency and 
biliary retention may help to elucidate this problem, as in the case 
of xanthoma. If I am mistaken in this hypothesis, urticaria pig- 
mentosa will have to be considered as related to the nevi. 
• All treatment hitherto attempted, including hot and cold hydro- 
therapy, radiotherapy, phototherapy, electrolysis, etc., has on the 
whole proved useless. All that can be done is to prescribe a correct 
hygiene. 

Botryomycoma [Granuloma pyogenicum]. — This designation is 
applied to certain benign tumors, or rather persistent inflam- 
matory products which assume the behavior of tumors, possessing 
very peculiar morphological and histological features. 

There is sometimes seen on the hands or on the fingers, or on the 
sole of the feet, a small soft prominent elevation, bright red in color, 
smooth or resembling a raspberry, the size of a pea to that of a 
large hazel-nut; its essential feature consists in its being strangulated 
at the base, or even plainly pedunculated, as may be verified in 
doubtful cases with the help of a stylet or a hook. Less commonly, 
similar growths have been observed on the leg, the forehead, the 
lips and elsewhere. As a rule the patient will remember some 
puncture or wound which he has sustained at this point and which 
has been suppurating for a few weeks or months previously. He will 



VASCULAR AND CONNECTIVE-TISSUE TUMORS 



705 



generally admit having repeatedly cauterized or irritated it in various 
ways. These tumors may persist for years (Fig. 203). 

On histological examination they are found to consist of inflam- 
matory or embryonic connective tissue with large and abundant 
newly formed capillaries; briefly, showing the structure of chronic 
"proud flesh" [granulation tissue]. The epidermis is missing on 
their surface and usually stops at the level of the pedicle or slightly 
above it. 




Fig. 203. — Botryomycoma of seven months' standing irritated by traumatism and 
applications of nitric acid. 



The interest aroused by these peculiar small products and the 
inappropriate name they bear are due to the statement of Poncet 
and Dor, in 1897, to the effect that these inflammatory growths 
contained mulberry-shaped hyaline globules, sometimes visible to 
the naked eye, similar to those which had been described by Bol- 
linger under the name of botryomyces in the fungoid growths follow- 
ing castration in horses; it is now known that this appearance is 
not due to a parasite, but to cellular dege nerations of pycnotic type. 

Moreover, the coccus growing in yellow cultures which can be 
isolated from human as well as animal botryomycoses possesses no 
special features and is not entitled to the name of botryococcus 
ascoformans, applied to it by Kitt; it is nothing more nor less than 
the Staphylococcus aureus. It would therefore be justifiable to 
group the tumors caused by it under the heading of pyococcal 
dermatoses. 

[The name Botryomycoma, based on an erroneous pathogenesis, 
is obviously objectionable. The term granuloma pyogenicum , pro- 
posed by Hartzell, is to be preferred.] 
45 



706 TV MORS OF THE SKIN 

The treatment of these newformations consists in their complete 
ablation [followed by cauterization]; there is no danger of recurrence. 
[Nevertheless, unless they are thoroughly cauterized they often 
recur.] 

SARCOMA. 

Sarcomas are connective-tissue tumors of embryonic structure, 
usually possessing great malignancy. 

On the skin are observed: primary idiopathic .sarcoma, which 
alone will be considered here; and secondary metastatic sarcoma, 
derived from the generalization of sarcomatous tumors of the viscera, 
the glands or the bones. 

The primary cutaneous sarcomata belong to different varieties. 
From the histological point of view, a distinction can be made 
between the following: 

1. Round-cell .sarcoma, which consists either of small round cells 
or of large round cells. 

2. Spindle-cell sarcoma, with spindle-shaped or fasciculated cells. 

3. Atypical sarcoma with polymorphous cells which were errone- 
ously described by me in former publications and in the first 
edition of this book, under the name of lymphosarcoma. 

The so-called pigmented sarcoma is a nevocarcinoma (p. 682) 
which surgeons persist in calling melanotic .sarcoma. The multiple 
idiopathic pigmented sarcoma of Kaposi (1872) is a separate affec- 
tion, probably of infectious origin. 

A. Typical Sarcoma. — These tumors are characterized by their 
being composed almost exclusively of embryonic connective-tissue 
cells, all of the same type, round or spindle-shaped in different cases, 
not contained in an adenoid network and whose bloodvessels are 
lacunar, in the sense that their walls are formed by the tumor 
constituents themselves. 

This neoplasm of relatively homogeneous structure invades the 
neighboring tissues by substitution, not by interstitial infiltration; 
metastases occur by way of the bloodvessels rather than by the 
lymphatic route. These features are not invariable, however, for 
any sarcoma may present some rare dissimilar constituents, chorio- 
plaxes, giant cells, etc., as well as points of interstitial infiltration 
on sonic of its borders. 

Spindle-cell or fascicular .sarcoma, with large or small fusiform 
cells arranged in interlacing bundles, presents itself clinically under 
the aspect of a hard, indistinctly outlined dermo-hypodermic tumor, 
of a dark red or purplish color, interspersed with telangiectases; 
it grows slowly and finally becomes superficially ulcerated; it has 
only a slight tendency toward glandular or visceral metastases, but 
usually recurs promptly after surgical removal, 



SARCOMA 



707 



Round-cell sarcoma, with small or large round cells, develops 
more rapidly and usually becomes generalized. The initial tumor 
may be situated at any point of the body, except on the extremities ; 
whether operated upon or not, it becomes associated after a few 
months with secondary tumors in progressive number, from about 
twenty to several hundreds, first in the same region, then scattered 
on the trunk, the root of the limbs and the head with relative 
freedom of the hands and feet. Some of the tumors are at first 
hypodermic and movable under the skin, which presents a lavender 
hue and an orange-peel appearance, before it becomes invaded. 
Other tumors are dermic, pink, dark red, then purplish, the size of 
a pea or a hazel-nut to that of a mandarin orange, of hard or soft 




Fig. 204. — Generalized sarcomatosis. Woman, aged fifty-two years; onset in the 
pectoral region three years before; death in the course of the fourth year. 



consistence; after a certain time, they undergo ulceration through 
necrosis; followed by fever, diarrhea, hemorrhages, finally death 
due to cachexia, after a total duration of one to four years. The 
glands are found to be intact, but metastases are sometimes found 
in the lungs, liver and spleen. The blood at the period of the ulcer- 
ations presents a leukocytosis of 20,000 to 40,000, with predominance 
of the polynuclears. This pathological type, known as generalized 
sarcomatosis (Fig. 204) is observed especially in patients between 
forty-five and sixty years of age. 

Angiosarcoma is a malignant tumor, frequently multiple, de- 
veloping slowly in adults, more rapidly in children, consisting of 
fascicular sarcomatous tissue with telangiectases; opinions differ 



708 TUMORS OF THE SKIN 

as to its being an angioplastic sarcoma or an angioma which has 
become sarcomatous. These tumors have been observed especially 
on the scalp, in the upper part of the face and on the upper part of 
the trunk. 

Sarcomas with myeloplaxes are extremely rare and seem to be 
secondary to tumors of the bones. 

Parini is said To have observed a case primary in the skin. 

B. Atypical Sarcoma with Polymorphous Cells. — I have repeatedly 
drawn attention to this form of sarcoma, under the name of "lympho- 
sarcoma:" this denomination has the disadvantage of creating con- 
fusion by suggesting the identity of this form with the glandular 
lymphosarcoma of Kundrat-Paltauf (p. 653); since this identity 
seems to me in no way established, nor even probable, I have adopted 
the denomination given above, in my report of an illustrative case 
(Annates de Dermatologie, April, 1911, p. 220). 

This form of sarcoma is characterized histologically by a very 
special, alveolar or areolar structure on account of which it has 
received from the old anatomo-pathologists the names of alveolar 
sarcoma (Billroth) and reticular carcinoma (Cornil and Ranvier). 
The more or less dense network is sometimes adenoid, composed of 
fine fibrils, while in other cases it consists of larger fibrous strands, 
provided with connective-tissue cells ; or again it may be embryonic 
and myxomatous; or it may vary in appearance at different points 
of the same tumor. The constituents enclosed in its meshes are con- 
nective-tissue cells of embryonic or fetal type and very polymor- 
phous, being small and round, or rather large and round, or fusiform 
and stellate, sometimes multinuclear; among them plasmocytes are 
sometimes met with, but very few or no lymphoid or myeloid con- 
stituents; the polynuclears are numerous in ulcerated tumors. 
The bloodvessels, instead of being purely lacunar as in the other 
sarcomata, have distinct walls, but without elastic fibers. The 
boundaries of the tumor are less distinctly outlined than those of the 
other sarcomas. 

Clinically, these polymorphous alveolar sarcomas are, after the 
epitheliomas, the most common primary malignant tumors of the 
skin. They are observed in both sexes, in adolescence or adult life, 
preferably in the vicinity of the natural orifices. 

The process begins as a small pink intradermic nodule, of firm 
consistence; this develops in breadth rather than in thickness, 
finally giving rise to a large, hard, globular or spreading tumor, 
which for a long time remains solitary, more or lesss rapidly under- 
going erosion or ulceration. A large and hard, sometimes also 
ulcerated glandular enlargement is noted at an early stage, which 
does not occur in any other form of sarcoma. Secondary nodules 
finally develop in the vicinity; generalization takes place by the 
lymphatic route, as in the case of the epitheliomas. 









SARCOMA 709 

This variety is thus seen to differ in many respects from the so- 
called typical sarcomas. 

C. Multiple Hemorrhagic Sarcomatosis. — This designation is 
applied to a disease which is clearly differentiated by its clinical 
behavior and by the structure of its lesions; their character, how- 
ever, is probably very different from that of the sarcomas. It is 
the idiopathic pigmented sarcoma of Kaposi. 

It begins at the extremities, or as a solitary tumor at any point, 
sometimes as the sequel of a local traumatism; lesions promptly 
develop on the feet and hands, nearly always symmetrically. 

There are either very hard edematous swellings, livid or slate- 
colored, in spots or in patches, often imperfectly outlined; or 
small tumors, miliary or pea-sized, at first intradermic, then pro- 
tuberant or even pedunculated, often agminated. These tumors, in 
very variable number, appear on the infiltrated surfaces as well as 
on the healthy skin; they vary in hue from a dark rose color to 
purplish and black; hemorrhagic spots are likewise noted. The 
lesions progress from the periphery to the center; after the legs and 
the forearms, the thighs, the genital organs, the mouth, the back and 
finally the internal organs are invaded. Movements are consider- 
ably impaired, but the pain is moderate; the tumors and infiltra- 
tions never assume a marked development, they have only a slight 
tendency to ulcerate and are even capable of undergoing sponta- 
neous absorption. The glands usually remain free. The general 
health may be good until the terminal stage is reached. 

Kaposi's sarcomatosis attacks especially men from forty to sixty 
years, particularly laborers, but sometimes children. It lasts from 
two to ten years and leads to death through generalization, with 
fever, cachexia, hemorrhages, etc. It is not rare in Poland, Russia, 
Austria and Italy, but altogether exceptional in France. [In 
America it occurs almost exclusively among Jews, possibly because 
the great majority of our Russian, Austrian and Polish immigrants 
belong to this race.] 

Histologically, the lesions consist of a newformation of dilated 
capillary bloodvessels, with lymphatic dilatations and collections of 
round and fusiform cells arranged parallel with the vessels in vari- 
able proportions. The pigment is hemosiderin, of hemorrhagic 
origin. 

There is a tendency to question the neoplastic character of this 
disease and to consider it as infectious; its pathogenic agent is 
unknown; it is not auto-inoculable and does not seem to be con- 
tagious. 

Diagnosis of the Sarcomas. — As many sarcomas are hypodermic 
at the onset, their differential diagnosis must be made from all the 
nodosities (Chapter XIV), the gummas and especially the sarcoids, 



710 TUMORS OF THE SKIN 

and furthermore from the benign subcutaneous or cutaneous tumors, 
and from adenitis or certain subacute or chronic phlegmons. 

Secondary carcinoma of the skin, nevo-carcinoma, cylindroma, 
mycosis fungoides, the leukemic tumors can sometimes be differ- 
entiated only with considerable difficulty. 

The polymorpho-cellular sarcoma may closely resemble epithe- 
lioma, certain forms of cutaneous tuberculosis and even syphilitic 
chancre. 

The hemorrhagic sarcoma of Kaposi must be distinguished at the 
onset from nevo-carcinoma, from botryomycoma, from scleroderma; 
and in the course of its development, from the tertiary syphilides, 
from lupus and more particularly from leprosy, certain cases of 
which have very closely simulated it in my experience. 

In all doubtful cases, biopsy and histological examination as well 
as cytological analysis of the blood will be required for the confirma- 
tion of the diagnosis; it is advisable to resort to these procedures 
even when the clinical features and the course seem more or less 
convincing by themselves. 

Treatment. — Surgical removal is to be recommended only at the 
very beginning, before generalization has had time to occur and must 
be as early and extensive as possible. In its absence, or directly 
afterward and as complementary measures, the following treatment 
should be employed: 

Arsenic has at all times been universally advocated against every 
form of sarcoma; it is given in large doses and particularly in hypo- 
dermic injections of potassium or sodium arsenite. At the present 
day, intravenous injections of arsenobenzols are of course entitled 
to a preference. It has seemed to me as to many others, that the 
progress of sarcoma is delayed for some time under the influence of 
arsenic. [On the use of arsenic in chronic diseases see my note p. 661 .] 

The other treatment which has been found of value, at least in a 
certain number of cases, is radiotherapy; it has not been demon- 
strated that radium is more efficient, except in certain regions not 
readily accessible to the .r-ray tube. The .r-rays are certainly 
capable of diminishing the size and even of causing the absorption 
of sarcomas, but this is far from saying that they can effect a com- 
plete cure. Of course, large doses are administered in such cases; 
opinions differ concerning the necessary degree of filtration and the 
general plan of the treatment which notwithstanding the gravity 
of the condition must nevertheless be cautiously conducted. It 
goes without saying that these two therapeutic procedures may and 
should be employed concurrently. 

Unfortunately, the physician is often consulted too late, when 
generalization is under way and all treatment has become powerless; 
so that sarcoma still has an extremely serious prognosis. 



APPENDIX. 



THERAPEUTIC NOTES. 

On undertaking the treatment of a dermatosis, as with any other 
pathological condition, it is necessary to look into the therapeutic 
indications to begin with, as soon as a positive diagnosis has been 
made. What is to be done? What kind of medication may prove 
beneficial? By what kind of intervention may one hope to cure, 
that is, to restore the organism, as far as possible, to a normal 
condition? 

The choice of the method must therefore necessarily precede the 
choice of the remedy. Nothing could be more unreasonable than 
to take up a formulary and blindly order some medicinal compound, 
without knowing the mechanism of its action and consequently the 
effects which it may produce. 

The reason for the selection of a given remedy is sometimes 
supplied by the cause of the disease, when this is known and can be 
so acted upon as to remove it (examples : scabies, syphilis) ; in other 
cases it is the pathogenic mechanism which can be influenced; but 
more frequently, at least in dermatological practice, the lesions 
themselves dictate the mode of intervention, according to their 
nature, morphology and degree. It is really of minor importance 
from the therapeutic point of view, if an acute eczematiform derma- 
titis, for instance, be due to a physical or mechanical agent, or to 
this or that chemical substance; what has to be checked is the 
inflammation, the oozing, itching, etc.; what has to be foreseen, in 
order to prevent it, if possible, is the superadded infection; what 
must be aimed at is not to inhibit but on the contrary to favor 
cellular regeneration. 

At the end of each section of this book, I have taken pains to 
indicate briefly the kind of medication adapted to the cutaneous 
affection or to the disease under consideration. 

Here I propose to enter into greater detail concerning some of the 
modes of treatment. 

It would be a waste of time, at the present day, to compare the 
relative value of internal and external treatment in dermatology. 
Each has its own domain, determined by the cause and nature of the 



712 APPENDIX 

pathological process on the one hand and by the general condition of 
the patient on the other. Xo general remarks of practical value in 
this connection are possible. 

I shall not dwell upon the different measures which constitute 
the armamentarium of the general treatment of skin diseases; these 
belong to the domain of general medicine. It goes without saying 
that the general hygiene, the cutaneous hygiene, the diet (to which a 
paragraph will be devoted at the end of this chapter) and even the 
emotional hygiene — all of which play a part in the etiology of certain 
cutaneous affections, require great attention and must be corrected 
in a considerable number of cases. 

In the course of this work, I have repeatedly pointed out the 
advantages offered by hydrotherapy, climatotherapy, heliotherapy, 
watering-places, the various groups of sera, by opotherapy, vaccino- 
therapy, ferments and yeasts, etc. 

In regard to internal pharmaceutic remedies, I have had occasion 
to supply some information concerning those of capital importance 
or most frequently employed in dermato-therapy (arsenic, arseno- 
benzols, mercury, etc.). A lengthy discussion of this subject would 
take me beyond the limits assigned to this book. I restrict myself 
to the reminder that the medicinal agents most frequently required 
include the following: the laxatives, quinine, cod-liver oil, calcium 
salts, phosphoric acid, phosphates and glycerophosphates, iodides 
and iodine-tannin preparations, chaulmoogra oil, sulphur and its 
compounds, iron, valerian, etc. 

The local treatment likewise comprises various procedures or 
modes of action; their indications have been mentioned, but they 
cannot here be described in detail. 

They can be classified under four headings, as follows: 

1. Surgical extirpation, applicable especially to a large number of 
tumors, certain cases of lupus, etc. 

2. Dermatological operations, curettage, scarifications, epilation, 
and cauterization; this technic and the results which can be obtained 
are admirably described in the writings of my colleague and friend 
Dr. Brocq, notably in his Traite de Dermatologie pratique (O. Doin, 
Paris, 1908, Vol. I), to which the reader is referred. 

3. The different forms of physico-therapy (electrolysis, static 
electricity, Franklinization, high frequency, radiotherapy with 
.r-rays, radium and radio-active substances, phototherapy, light- 
baths, Bier's method, treatment with hot-air or carbonic acid snow, 
massage, etc.). These methods are described in special text-books 
and it would be futile to offer a necessarily very incomplete and 
inadequate summary. 

4. External medicinal treatment. 



THERAPEUTIC NOTES 713 

This chapter is devoted almost exclusively to the external medi- 
cinal treatment. 

No complete dermatological formulary should be looked for, as 
I have on the contrary endeavored to incorporate in these notes 
only the customary substances and prescriptions or those with 
which I am personally acquainted. It has long been may conviction 
that good dermatologic treatment is practicable with the help of a 
very limited number of procedures and remedies. Inexperienced 
practitioners even more than experts in the field should refrain from 
experimenting with poly-pharmacal medication, but unfortunately 
the contrary is often the case. 

The order followed in my account is that of the remedies which 
correspond to the clinical indications. Although it seems to be 
logical and convenient enough, the fact must not be overlooked 
that an arrangement on this basis possesses more apparent than 
real value. 

Many medicinal agents, including some of the most valuable, 
have an unknown or hypothetical mode of action; furthermore, the 
same substance may have multiple effects ; moreover, its action may 
be entirely different, or even opposite, according to the concen- 
tration in which it is employed, according to the duration of its 
application and according to its pharmaceutic form or its vehicle. 

The 'pharmaceutic form, or let us say the physical state of an 
active or inert substance which is utilized as a topical agent, has a 
marked influence on its effects; this very important fact has been 
brought out by the contributions of Unna and his school. Some 
explanation here may not be superfluous. 

The skin under normal conditions is covered with a protective 
layer, the horny epidermis. 

The latter, composed essentially of keratine and fat, forms on its 
surface a sort of supple and resistant varnish, practically imper- 
meable to water and aqueous solutions, but more or less permeable 
to fatty bodies, volatile substances and gases. 

Perhaps the most important function of the horny layer is to 
oppose the evaporation of water from the body tissues; without it, 
an enormous loss of water would take place over a surface as exten- 
sive as that of the entire integument and at the temperature of the 
body. However, undoubtedly due to the sweat pores and follicles 
with which it is riddled, the normal skin is constantly the seat 
of a fairly considerable watery evaporation known as "insensible 
perspiration." This contributes powerfully to the regulation of the 
general temperature of the body and the local temperatures of the 
various tegumentary regions. 

It is now necessary to keep in mind the modifications which this 



714 APPENDIX 

physiological function may undergo through pathological changes 
of the skin on the one hand and through topical applications on the 
other. When the skin is congested or inflamed or when its horny 
covering is absent or defective, the evaporation is considerably 
increased. Among the topical agents, those which tend to increase 
evaporation are necessarily cooling and relieve congestion; whereas 
those which inhibit evaporation will have a heating and congestive 
effect. 

The mode of action of the customary agents of topical treatment 
will be briefly examined in the following, in the light of the above 
data. First, however, it seems advisable to point out a mistake 
very frequently committed in practice, but which it is important 
to avoid; it consists in the application of alterative dressings, 
ointments or medicated plasters over crusts, scales, or hyperkeratotic 
layers. Even if the topical agent be judiciously selected, it must be 
remembered that the remedy is separated from the surface on which 
it is to act by a stratum or layer of dead and isolating substances. 
Xo one would dream of interposing a sheet of paper or a bit of shirt 
between an application and the diseased skin! // is therefore always 
necessary at the start to cleanse, denude or freshen, every tegumentary 
lesion which it is proposed to treat. 

Water and Watery Solutions. — Baths, douches, sprays, washes and, 
better still, poultices and moist occlusive dressings whose action is 
more prolonged, are the most efficient and most commonly utilized 
cleansing agents; their general effect is moreover to relieve conges- 
tion. The macerated epidermis becomes more permeable. 

Alcoholic, Ethereal Solutions, etc. — Alcohol, ether, acetone, chloro- 
form, benzene, carbon disulphide and carbon tetrachloride, all 
more or less dissolve fatty substances, notably the epidermic fats; 
they accordingly have a cleansing and drying effect. I habitually 
employ a few drops of benzin to cleanse the surfaces for examination. 

These bodies likewise dissolve certain medicinal substances insol- 
uble in water; by acting as vehicles they favor their action, permit- 
ting them to penetrate down to the vicinity of the active layers of 
the epidermis. But the irritative effect of solutions of this kind 
restricts their application to a few special cases. 

Powders. — By virtue of their mere physical properties, powders 
increase the surface of evaporation and thereby exert a cooling, 
drying action and relieve congestion. These effects increase with 
their power of absorption. 

The first rank from this point of view belongs to a f ossiferous 
earth, known in France as " ceyssatite;" this is a natural product, 
an earth composed of the silicious shells of foraminifera; a small 
quantity of this powder suffices to transform a salve into a thick 



THERAPEUTIC NOTES 715 

paste. The only objection to ceyssatite is that it is not readily 
obtainable. [It is identical with Unna's Kieselgur or Terra silicea.] 
Other so-called inert powders, both mineral and vegetable, have the 
same properties, but to a lesser degree. 

The mineral powders chiefly used are the following: talc, zinc 
oxide, the carbonates of calcium, magnesium or bismuth, the sub- 
nitrate of bismuth, kaolin or bolus alba; vegetable powders: corn, 
rice or potato starch, various flours, lycopodium. It must be kept 
in mind that starches and flour have the disadvantage of swelling 
on exposure to moisture and of undergoing fermentation. 

In order to render powders more adherent, they can be incor- 
porated in weak proportion with lotions or better in larger propor- 
tion with glycerinated or mucilaginous fluids, forming watery pastes. 
[The popular calamine lotion belongs to this class of powders in 
suspension in a watery fluid. Calamine is (nowadays) an artificial 
carbonate of zinc stained a pink color; a convenient formula is: 
1$ — calaminse prsep., 3.0; zinci oxidi, 4.0; glycerini, 1.0; aq. rosse, 
100.0 M. Various soluble drugs may be incorporated in this mix- 
ture; e. g., boric or salicylic acid, resorcinol, etc., or other insoluble 
powders added, e. g., sulphur precip.] 

Glycerine. — Glycerine, which when pure is very hygroscopic and 
is miscible with water in any proportion, and its derivate, glycerite 
of starch, are less emollient and less cooling than watery solutions; 
on the other hand, when employed in dressings, they are superior to 
wet-dressings in that they reduce the risk of auto-inoculation with 
pyococci. Compared to fatty bodies they are less heating, but lend 
less suppleness to the horny layer. 

Glycerite of starch with an addition of inert powders makes a 
very good paste which can be mixed with various active remedies 
and is easily removed by washing. 

Watery Pastes. — These are mixtures of equal parts of powder and 
dilute glycerine. They are easily prepared, convenient and clean 
in use ; moreover, not expensive, so that they are liked by patients 
and deserve their growing popular favor. They are applied in a thin 
layer, with a flat brush, left to dry for an instant, then covered with 
a generous sprinkling of talc; no dressing is necessary; they may be 
removed by washing with water. 

The simplest type of watery paste is composed of equal parts of 
zinc oxide, talc, glycerine and water. The talc may be replaced by 
calcium carbonate or starch. A number of liquid or powdery 
medicinal agents can be introduced into these pastes, such as 
ichthyol, coal-tar emulsion, lead-water, borated water, lime-water, 
precipitated sulphur, etc., care being taken to observe that the pro- 
portion of glycerinated fluid and powder remains the same. The 
addition of § per cent, of gum Arabic renders these pastes more 






716 APPENDIX 

adherent; the addition of 5 to 10 per cent, of alcohol makes them 
more drying. 

The various watery pastes are especially adapted to the treat- 
ment of the inflammatory and pruritic non-oozing dermatitides. 

Fatty Bodies. — The fatty or oily bodies, which serve for inunctions, 
play an important part in dermatotherapy, lending themselves well 
to lasting and extensive local applications. They adhere to the 
epidermis and slightly penetrate it, making it supple, swelling the 
horny cells and detaching the scales. But they prevent the evapor- 
ation of the secretions and the cutaneous perspiration in proportion 
to their impermeability to water, thereby acquiring a congestive 
and heating effect. 

In this respect, enormous differences exist between the various 
substances designated as fatty bodies on account of their compo- 
sition. In this group belong: (1) Fats properly speaking, solid, 
pasty, or oily, of animal or vegetable origin (fresh or benzoinated 
lard, beef-marrow, whale oil, cacao butter, sweet almond oil, olive 
oil, castor oil, cod-liver oil), which are glycerine-ethers or triglycer- 
ides. Fats admit the incorporation of only a very small proportion 
of water; they are capable of saponification and turn rancid in the air. 
(2) Hydrocarbons, such as the vaselines, petroleum, paraffins, etc.; 
these are not at all miscible with water; they do not change on 
exposure to the air. (3) Wool fats (adeps lame, lainine, lanoline 
[eucerine] which are cholesterine ethers; large amounts of water 
can be incorporated into them (over 300 per cent.), transforming 
them into creams. The French Codex of 1908 designates as lanoline, 
wool-fat mixed with water to a proportion of 25 per 100. 

The consistence of the fatty bodies may be arbitrarily varied by 
combining those which are liquid, such as the oils, or of slightly fluid 
consistence, such as lard and vaseline, with more viscid fats, like the 
wool-fats, or solid fats, like beef-marrow, spermaceti, cacao butter, 
or even with wax or paraffin. The resulting mixture retains the 
general properties of its constituents. 

There are other additions, notably those of powders or water in 
considerably proportion, which modify not only the consistence, but 
also very notably the immediate effects of the fatty bodies. 

Salves. — Salves are natural or combined fatty bodies into which 
one or several medicinal substances has been incorporated. As 
these salves are always more or less impermeable to the cutaneous 
perspiration, they have a heating, congestive effect, as mentioned 
above; but at the same time they favor the real and deep action of 
the active substances contained in them. 

Salve Sticks. — Mixed with wax, paraffin, etc., salves may be 
moulded into sticks, which are easy to manipulate and very con- 
venient. 



THERAPEUTIC NOTES 717 

Pastes. — By mixing the fatty bodies with a considerable quantity 
of powders (on the average, equal parts of fats and powders), fatty 
pastes are obtained. These soften and protect the skin surface on 
which they are applied; they moreover possess the essential property 
of being porous, permeable to perspiration, consequently relieving 
congestion. Medicinal substances incorporated into a paste have a 
moderate action, intermediate between that of salves on the one 
hand and of creams and watery pastes on the other. 

Creams. — Creams are formed by an intimate admixture of fatty 
bodies with a large proportion of water or of watery solutions. 

The relative quantity of water contained in the different creams 
is very variable; 17 per cent, in cold cream; 33 per cent, in "Galien 
cerate;" 43 per cent, in "cucumber cream;" 50 per cent in oil- and 
lime-water liniment. Mixtures of wool-fats and vaseline are best 
adapted to the manufacture of creams very rich in water (up to 
1000 to 100) and do not turn rancid. 

Creams cannot serve for active treatment, but are cooling and 
softening. 

Milks, several varieties of which are offered in trade (notably the 
milk of Sapolan, the collosols, etc.), are emulsions of hydrocarbons, 
lanoline, etc., and possess analogous although mild properties. 

Soapy salves are useful as cleansing agents. 

Occlusive Dressings. — Zinc gelatine is permeable to perspiration 
and has a protective action, relieving congestion and itching. 

Plasters, sparadraps or epithems, are formed by some tissue or 
fabric covered with a layer of a plastic substance of such consistence 
as to adhere firmly to the skin. The older plasters, consisting of 
litharge, lard and various resins, which are apt to crack and fre- 
quently have an irritating effect, are now advantageously replaced 
by plasters prepared with a base of lanolin or vaseline, caoutchouc 
and a little wax. Practically all external dermato-therapeutic agents 
may be incorporated into these plasters, in variable proportions. It 
must be kept in mind that all plasters, being impermeable, prevent 
evaporation and cutaneous perspiration, so that they have a heating 
and congesting effect. 

Varnishes soluble in water (caseine ointment, gelanthum and 
analogous preparations) have not been adopted in current derma- 
tological practice. [A varnish of ichthyol and water, equal parts, 
is valuable in many acute erythematous conditions, e. g., acute 
dermatitides, erysipelas, etc.] 

Ether varnishes (collodion), acetone (filmogen) ["new-skin"] and 
chloroform varnishes (traumaticine) are employed only in certain 
special conditions. 



718 APPENDIX 

After this brief review of the pharmaceutic forms under which 
the medicinal agents used in dermato-therapy are employed, these 
agents will now be considered as such, arranged by their therapeutic 
indications. 1 repeat the reservations previously stated concerning 
the value of this classification. 

Where a series of simple or compound substances appear in the 
same paragraph, they may be regarded as analogous; but they 
differ necessarily among themselves by shades which I have not 
always found it possible to indicate. 

The somewhat complex combinations have been presented in the 
form of prescriptions, sometimes signed with the name of their best 
known author. It should be clearly understood, however, that there 
is nothing binding about these prescriptions; the excipients have 
been purposely varied, to serve as examples, so that a given excipient 
may always be replaced by some other of analogous consistence and 
the same physical properties. 

The majority of the prescriptions are given on a basis of about 100 
parts, as an aid to memory; it is left to the physician to estimate the 
quantity of remedy required in a given case. 

[It may be useful to remember that 25 grams of a soft ointment, 
of the consistence of vaseline, is ample for a single inunction over 
the entire cutaneous surface of an adult; twice that amount is 
hardly enough to cover the surface with a firm paste like Lassar's.] 

1. ANTIPHLOGISTICS. 

Antiphlogistic, sedative, cooling and emollient treatment is em- 
ployed in the acute dermaiitides in general, in the active erythemas, 
eczema, etc. Cases in which it is indicated are therefore extremely 
common. It comprises several procedures between which a selection 
must first be made according to circumstances, but which are often 
employed in combination or successively. 

These procedures consist of the use, under different forms, of 
water and watery solutions, especially to be recommended when 
crusted surfaces have to be cleaned at the same time; of powders 
and watery pastes; of creams, milks, or glycerites and more rarely, 
of fatty pastes or salves. 

Lotions {washes). — Preferable to simple boiled water is an infusion 
of camomile flowers, lime- or elderblossoms, or a decoction of ele- 
campane roots, marshmallow, etc., or some isotonic solution may 
be used, such as physiological salt solution, or better the cytoplastic 
solution of Professor Delbet (magnesium chloride, dry, 12.10, or 
crystallized magnesium chloride 25.85, to one liter of water) with 
which I have been especially well pleased of recent years. Weak 



ANTIPHLOGISTICS 719 

antiseptic and astringent solutions may also be employed (§2). 
Lotions should usually be applied hot and several times daily. 

Sprays. — The above-mentioned solutions may be employed as 
sprays, by means of a Richardson apparatus or vapor spray, repeated 
several times daily. 

Moist Occlusive Dressings. — These are used every day in derma- 
tology even more than in surgery. 

Moist dressings consist of compresses of sterilized gauze, soaked 
in one of the above-mentioned infusions, decoctions or solutions, 
well squeezed out so as to be merely damp, then applied so as to 
cover widely the affected region; they are covered with an imper- 
meable layer of rubberized cloth, oil-silk, or gutta-percha, with a 
margin to spare on all sides; next, with a layer of cotton; the whole 
is held in place by a bandage. These dressings should generally be 
applied cold; they must be really occlusive and be renewed once or 
twice in the twenty-four hours. [The Liq. aluminii acetatis diluted 
with 10 to 15 parts of water is especially valuable for its astringent 
and mildly antiseptic properties.] 

Poultices. — On account of their mucilaginous consistence, these 
are often better tolerated than moist dressings. They are prepared 
as follows: Mix with two spoonfuls of cold water, a spoonful of 
mashed potato or starch; slowly pour this dilution into a sauce- 
pan containing eight spoonfuls of boiling water for the mashed 
potato, not more than six spoonfuls for the starch, stirring to a 
jelly; then spread on muslin, folding the borders over the mixture. 
Linseed meal, the oil of which turns rapidly rancid, is not to be 
recommended. Ready-made starch and other poultices are on the 
market which only need to be softened in a little luke-warm water. 

Poultices are applied cold or barely luke-warm and renewed two 
or three times daily; it is not usually necessary to cover them with 
an impermeable material. [Salicylic acid, one per cent., or boric 
acid, 5 per cent., may advantageously be dissolved in boiling water 
in preparing these poultices.] 

Baths. — Aside from local warm baths, which are indicated for 
example in lymphangitis, general baths of pure water, baths of starch 
water, lime blossom decoctions, gelatins, etc., are oftener harmful 
than useful in erythemas, urticarias, acute eczemas and especially in 
the presence of a complicating pyodermatitis. 

Alcohol Dressings. — This therapeutic procedure, inherited from 
Ambroise Pare, is not sufficiently appreciated. It is highly useful 



720 APPENDIX 

and may serve at the onset to abort furuncles and carbuncles, 
lymphangitic abscesses, bvbos, etc. The compresses should be soaked 
in 9o° or 90° alcohol, no weaker; covered with impermeable material 
and renewed every twelve or twenty-four hours, according as the 
occlusion has been more or less perfect. 

Powders. — It has been previously stated that absorbent or inert 
powders are far from being useless; they have on the contrary a 
cooling, drying action and [by increasing the surface for evaporation] 
evidently relieve congestion. 

Various powders are often combined and coloring substances may 
be added to the mixture if desired by the patient, or they may be 
rendered slightly antiseptic or antipruritic. 

Two examples follow, meeting each of these two indications: 

PULVIS CUTICOLOR (UNNA). 

Rice starch 40.0 gr. 

Zinc oxide 25.0 

Magnesium carbonate 20.0 

Bolus alba 12.5 

Bolus armenian 2.5 

COMPOUND POWDER. 

Talc, venet 40.0 gr. 

Calcii carbonat. 
Magnesii carbonat. 

Zinci oxidi aa 20.0 

Ichthyol or gomenol 1 to 2 . 

Ointments. — The only ones usually to be recommended in cases 
of acute dermatitis are watery pastes, creams, and sometimes 
glycerites, etc. 

Watery pastes may be simple or compound: 

SIMPLE WATERY PASTES. 

Zinc oxide, talc, glycerin, water equal parts 

or 

Zinc oxide, calcium carbonate, glycerin, lime-water . . equal parts 

COMPOUND WATERY PASTES. 
Zinc oxide, 

Starch aa, 25.0 gr. 

Glycerin, 

Water aa 20.0 

Ichthyol 10.0 

Gum Arabic, powd 0.5 

These pastes are applied with a flat brush, left to dry for half a 
minute, then covered freely with talc. 

Among the creams, namely mixtures of fatty bodies and a large 



ANTIPHLOGISTICS 721 

proportion of water, may be quoted: cold cream, Galien cerate, 
cucumber cream, lime- and oil-liniment (almond oil and lime-water 
in equal parts). I prefer the following creams, because they do not 
turn rancid: 

VASO-LANOLINE. 

Petrolati 10.0 gr. 

Lanolini anhydr 5 . gr. 

Aq. rosae, 

Aq. lauro-cerasi, 

Aq. aurant. flor aa 5.0 

Triturate well, adding the waters drop by drop. If lime-water be substituted for 
oneof the'scented waters the emulsion is facilitated and keeps better. 

CREAM OF STEARATE OF SODA. 

Liq. sodse 5.0 

Ac. stearic 25.0 

Glycerin 75.0 

Aq. rosffi 120.0 

Heat and mix ; solidify by cooling, then heat again, stirring vigorously. 

QUININE VASOLANOLINE (PREVENTIVE OF SOLAR ERYTHEMA). 

Petrolati 10.0 

Lanolin anhydr 5.0 

Aqueous solution of neutral bromhydrate of quinine 1 to 15 . 15.0 
Apply before exposure to the sunlight and powder with 

Talcum 15.0 

Basic quinin sulphate 1.0 

Certain oils (pyroleol of Edet, phlyctol of Robert and Carriere, 
which are compound purified and sterilized oils of melilotus), applied 
in dressings, have a soothing and truly analgesic action, valuable 
in burns, phagedena and gangrenous ulcers. 

Starch glycerite, Sapolan cream, soapy salves and "diadermine" 
which is a glycerite of stearates, can sometimes substitute the 
creams. 

Milks, Sapolan or others, which are emulsions of lanoline and 
hydrocarbons, are cooling and much liked by patients. 

In the acute dermatitides, pastes and especially salves should be 
avoided; they are often very badly tolerated; fresh lard, however, 
is frequently very soothing. 

When the inflammation is plainly subacute, simple pastes or 
pastes with a slight admixture of ichthyol may prove serviceable. 

LASSAR'S PASTE. 
Zinc oxid, 
Starch, 
Vaselin, 
Lanolin aa equal parts 

SOFT PASTE OF UNNA. 
Zinc oxide, 
Prepared chalk, 
Linseed oil, 

Lime-water aa equal parts 

46 



APPENDIX 



GLYCEROL ICHTHYOL PASTE. 

Neutral glycerite of starch 70.0 

Kaolin, 

Magnesium carbonate aa 15.0 

Ichthyol 3 to 5 . 

ZINC, OIL AND ICHTHYOL. 

Olive oil washed with alcohol 40.0 

Zinc oxide 60.0 

Ichthyol 1 to 3 . 



2. WEAK ANTISEPTICS AND ASTRINGENTS. 

It has come to be understood, especially of recent years, that 
antiseptics applied for the purpose of killing the microbes or inhibit- 
ing their growth, are at the same time injurious to the tissues, the 
more so in proportion to their activity. It is therefore not practi- 
cable to disinfect a wound or an infected cutaneous surface all at 
once by means of a strong antiseptic. In order to attain this end, 
or at least to favor the organism in its fight against the infecting 
agents and thereby to assist the cure, only so-called cytophylactic 
substances should be employed, namely substances which spare the 
cells; or mild antiseptics as slightly injurious to the body tissues 
as possible. 

Lotions and Sprays. — In the majority of the cases, it is advisable 
in my opinion not to make an excessive use of lotions. When there 
is reason, however, for cleansing a wound, an ulcer, or an infected 
dermatosis, one of the following watery solutions may be employed: 
the classical borated water (boric acid 4 : 100), boricine, or biborate 
of soda obtained by the action of boric acid on borax, in equal parts 
and hot (4 to 10 : 100), dilute peroxide water, weak carbolized water 
(phenol 1 : 100), resorcinated water (resorcinol 1 :200), phenosalyl 
or a solution of phenol salicylate (1 : 200), decoctions of cinchona, 
oak bark or other astringent, tannic acid decoctions, and finally a 
solution of lead subacetate [Liq. plumbi subacetat. dil.]. 

Matchless, in my opinion, is Alibour water [copper and zinc 
sulphate in camphorated water] which renders me every day the 
most valuable service and Labarraque's fluid, or the officinal 
solution of soda hypochlorite, which should be diluted with water to 
4 to 10 times its volume; or better still, Dakin's solution. Burrow's 
solution [Liq. alumin. acetat.] is extensively used abroad. 

ALIBOUR WATER (PYODERMATITIDES). 

( lupric sulphate 2.0 

Zinc sulphate 7.0 

Camphor water saturated 300.0 

Filter; for use dilute a tablespoonful or two to a glass of water. 



WEAK ANTISEPTICS AND ASTRINGENTS 723 

burrow's solution (oozing dermatitides) . 

Alum . . . 1.0 

Plumbic acetate 5.0 

Water 100.0 

Not to be filtered; shake before use and dilute with 5 to 20 volumes of water. 

[Burrow's solution is best prescribed as liq. alumini acetatis; diluted before use 
with 10 to 20 volumes of water.] 

Moist Antiseptic Dressings. — All the above enumerated solutions 
may be employed for moist occlusive dressings, of course in their 
weakest solutions. The only exception is Alibour water, which is 
inefficient in dressings, in my experience. The question of the 
aseptic, antiseptic and other dressings will be taken up later on. 

Baths. — Local baths, with mild antiseptics, may be useful in the 
acute dermatitides and lymphangitides of the limbs and of the penis. 
For general baths, I make use only of zinc sulphate (20 to 40 grams 
for a full bath) in the generalized pyodermatitides. 

Solutions for Painting, Touching, etc. — Although they must not be 
abused, it may be useful to know the preparations which may be 
employed in ulcers, atonic wounds, folliculitis, herpes, etc. Tincture 
of iodine is really used to excess at the present time, but is never- 
theless valuable for painting, as well as iodo-acetone (2 to 5 : 20) 
or iodo-chloroform (1 to 15), for aborting boils and in the epidermo- 
mycoses. The Lugol-Gram solution (iodine, 1 gr. KI, 2 gr., water 
300 gr.) serves for tuberculous or mycotic ulcers; iodoform ether 
(1 : 20), guaiiacol oil (equal parts), gomenol oil (5 to 20 : 100), in 
tubercidous or sluggish idcers; camphorated iodoform oil (3 : 10 : 100) 
makes a good dressing for soft chancres and bubos (Dinet). Cam- 
phorated alcohol (1 : 100), borated alcohol (1 : 16), alcohol with 
resorcin (1 : 50) or alcohol with thymol (1 : 100) and borated glycer- 
ine (1 : 100) or carbolized glycerine (1 : 50) are useful for touching 
or brief application during a few minutes in herpes and folliculitides 
such as furuncles of the auditory meatus, etc. 

Gargles {stomatitis and buccal ulcerations). — Dilute Labarraque's 
solution (50 : 1000), hydrogen peroxide water, "Neol" (1 : 10), a 
few drops of tincture of ratanhia or myrrh in a glass of water; 
decoction of snake-weed (bistorta) (20 : 1000); astringent gargles 
with alum, sodium borate, potassium chlorate; chloral hydrate 
(1 to 1.50 : 100), etc., with glycerine or honey. 

A soapy tooth-paste should also be recommended, containing 
sodium borate or extract of ratanhia, etc. 

GARGLE. 
Sodium chlorate, 
Sodium salicylate, 

Sodium bicarbonate aa 2.0 

Honey 75.0 

Water 225.0 



724 APPENDIX 



TOOTH-PASTE. 

Soap 10.0 

Carbonate of lime, 

Tricalcic phosphate aa 20. 

Carmin 0.1 

Oil of peppermint 3.0 

Collutories. — Iodized glycerine (iodine and carbolic acid aa 0.25, 
KI, 1.0; glycerine 50) in buccal ulcerations; borated glycerine 
(4 :30); or borated honey (5 : 20), For thrush; honey with alum 
(5 :30). 

Powders. — Iodoform, pure or camphorated (5 : 100) and its sub- 
stitutes: iodol (iodopyrol), diiodoform (C 2 I 4 ), aristol (diiodothymol 
or ihyrrvoliodide of Poulenc; europhen (butocresiol) , airol (oxyiodo- 
gallate of bismuth or alphaform); dermatol or officinal bismuth 
subgallate; xeroform (tribromophenate of bismuth or sigmaform); 
chemically pure methylene blue; tannoform (formotan); subearbon- 
ate of iron; cinchona, etc. 

To these more or less antiseptic powders which can be prepared 
in mixtures, as will be shown by an example, Vincent's powder has 
been added since 1017, which is very efficient through the nascent 
chlorine given off from it and but slightly irritant; it acts as a 
powerful preventive of infection on recent jagged wounds; more- 
over it yields good results in infected wounds and ulcers of variable 
character and even, in my experience, in soft chancre and chancroidal 
bubo. 

COMPOUND POWDER OF J. LUCAS CHAMPIONNIERE. 

Iodoform, 
Benzoin powder, 

Cinchona powder aa, 100.0 

Magnesium carbonate, 

01. eucalyptus 12.5 

Vincent's powder. 

Hypochlorite of lime 10.0 

Boric acid, dry 90.0 

Powder separately, mix well and preserve in a dry dark-glass bottle. 

Ointments. — Creams, glycerites, pastes or salves may be employed, 
in different cases, salves being the most active; one or several of 
the following remedies are incorporated: Yellow oxide of Hg. (5 to 
10 : 100); white precipitate (1 to 10 : 100); camphor (1 : 100); 
boric acid (5 to 10 : 100); salicylic a?id (1 to 2 : 100); resorcinol 
(1 to 2 : 100); naphthol (0.5 to 1 : 100); or various essential oils: 
gomenoloil (5 to 50 : 100). 

YELLOW SALVE (PYODERMATITIDES) . 
Yellow oxide of mercury, 

Oxide of zinc aa, 10.0 

Resorcinol, 

Salicylic acid aa, 1.0 

Vaselin 78.0 



WEAK ANTISEPTICS AND ASTRINGENTS 725 

ICHTHYOLATED YELLOW PASTE (iMPETIGENIZED ECZEMA). 

Ichthyol, 

Yellow oxide of mercury aa 5.0 

Resorcinol, 

Salicylic acid aa 1.0 

Oxide of zinc, 

Talcum aa 20.0 

Vaselin 48.0 

Ichthyolated Lassar's paste (5 per cent.) with an addition of 
resorcinol (1 : 100) or salicylic acid (1 : 100) is extremely useful 
and in daily use; the nature of the fats or powders which enter 
into the composition of the excipient may be arbitrarily changed, 
incorporating at will reducing agents, keratoplastic or antipruritic 
agents, etc. 

Starch glycerite with boric acid (100 : 10) is the topical applica- 
tion of choice in the treatment of boils, carbuncles and the pyoder- 
matitides in general (Gallois). 

Cold cream is a favorite vehicle for white precipitate (1 to 10: 100). 
with or without addition of tannin (1 to 5 : 100). 

Borated vaseline is in common use as a weak antiseptic salve. 
It is also employed for the nasal fossa?. 

gomenol-resorcinol salve (rhinitis, folliculitis of the 

nostrils) . 

Boric acid 10.0 

Resorcinol 2.0 

Gomenol 1.0 

Vaselin 50.0 

YELLOW EYE-SALVE (BLEPHARITIS, IMPETIGINOUS CONJUNCTIVITIS). 

Yellow oxide of mercury 0.15 

Guaiacol 0.05 

Lanolin 6.0 

Vaselin oil 10.0 



Varnishes. — Antiseptic varnishes find their indications in certain 
dermatitides with an intact epidermis (lymjihangitis, erysipelas); 
in these cases, thigenol, pure ichthyol or glycerinated liquid thiol 
(fluid thiol, 85; glycerine, 15) are serviceable; on the other hand 
as occlusives (fissures, rhagades, ulcerations of mucous membranes), 
use can be made of complex varnishes composed of various 
resins and balsams dissolved in alcohol or ether, which are generally 
found ready-made in the drug stores; such as Baume de Com- 
mandeur (Codex); steresol (Berlioz, Grenoble); adhesol (Leclerc). 
Varnishes having an aseptic action through their physical properties 
will be discussed later on. 



726 API'EXDIX 



■ I. STRONG ANTISEPTICS. 

The statements made at the beginning of the preceding paragraph 
suggest that the indications for strong antiseptic agents are rare 
and limited. 

The solutions and mixtures to be indicated in the following must 
under no circumstances be employed for dressings, as they would be 
too irritating and even caustic. They have to be reserved for washes, 
touching or painting. 

Watery Solutions. — Bichloride of mercury or corrosive sublimate 
(1 to 2 : 1000); biniodide of mercury (1 : 1000); cyanide of mercury 
2 to 5 : 1000; oxy cyanide of mercury (5 : 1000); strong carbolized 
water (phenol 5 : 1000); "microcidine" or naphtholate of sodium 
(3 to 5 : 1000); strong hydrogen peroxide water (12 to 20 volumes) 
" lusoform," "aniodol," or watery, alcoholic or glycerinated solu- 
tions of formol (0.25 to 1 : 1000)'. 

Various Solutions. — Tincture of iodine; iodized acetone (1 to 3 : 10 
camphorated naphthol (2 : 1); camphorated phenol (equal parts); 
camphorated salol (3:2). 

menctere's fluid (lacerated wounds, ulcers, etc.). 

Iodoform, 
Guaiacol, 

Eucalyptol, 

Bals. Peruv aa 1.0 

Alcohol 10.0 

Ether 100.0 

To be used as a spray or for painting. 

CALOT'S COMPOUND SOLUTION (TUBERCULOUS ULCERATIONS AND 
COLD ABSCESSES). 

Guaiacol 1-0 

Creosote 2.0 

Iodoform 9.0 

Camphorated naphthol 20.0 

Ether, 

Olive oil (sterilized) aa 34.0 

Ointments. — The following two salves enjoy a certain popularity: 

RECLUS' SALVE (SLUGGISH ULCERS) MODIFIED BY BROCQ AND II. PIED. 

Phenol crystal, 

Salicylic acid aa 1.0 

Resoreinol 2.0 

Camphor, 

Antipyrin iia 5.0 

Bals. Peruv 6.0 

Vaselin 80.0 

Dissolve the first four substances in a little alcohol and glycerin; dissolve the 
antipyrin in its own weight of water; then triturate the whole in a mortar. 



Antipruritic Agents And local Anesthetics 727 

OINTMENT OF LUCAS-CHAMPIONNIERE (BURNS). 

/3-Naphtholate of soda 0.3 

Oil of thyme, 

" geranium, 

" verbena, 

" origanum aa gtt. xv 

Vaselin 100.0 

4. ANTIPRURITIC AGENTS AND LOCAL ANESTHETICS. 

For the local treatment of pruritus, a series of procedures and 
remedies may be utilized. 

Watery Solutions. — These are usually more efficient when hot, 
although sometimes they act better luke-warm or cold. Decoction 
of elecampane root (20 : 1000); bran water; infusion of chamomile 
blossoms (20 : 1000) or lime-tree flowers (10 to 15 : 1000); an 
infusion of coca leaves (10 to 20 : 1000); lime-water; cherry-laurel 
water; chloral hydrate (2 to 4 : 100); Labarraque's solution (20 
to 50 : 100); phenol (1 to 5 : 100); saponin coal-tar (10 to 30 :100); 
sapolan milk, collosol with oil of cade or cod-liver oil, etc. [Liq. picis 
alk. or Liq. carbonis deterg. 10 : 100.] 

Baths. — These are often badly tolerated. Starch or bran baths 
are sometimes prescribed, with an addition of vinegar (1 liter) ; or 
baths of lime-tree flowers (1 kilo); finally, gelatine baths (250 to 
500 gr. of gelatine, soften in cold water, dissolve while heating and 
pour into bath). 

Various Solutions. — For painting or touching, the following are 
employed: Camphorated alcohol (1 : 10), or camphorated brandy 
(1 : 40), or camphorated chamomile oil (1 :10); resorcin alcohol 
(2 to 5 : 100); menthol alcohol (1 to 2 : 100); or mentholated oil of 
vaseline (1 to 2 : 100); carbolized glycerine (phenol 5, water and 
glycerine, aa 50); alcoholic solutions of silver nitrate (3 to 10 : 100); 
lemon juice. 

Especially advantageous are the alcoholic solutions of thymol 
(1 : 200), of carbolic acid (1 : 100), of coal-tar emulsion (5 to 10: 1000), 
to which castor oil or glycerine (5 to 10 : 100) are added to prevent 
their too rapid drying; cover with powder or a watery paste. 

ANTIPRURITIC SOLUTIONS. 
Vinegar, 
Camphorated alcohol, 

Aq. lauro-cerasi ■ aa 100.0 

Glycerin 50.0 

Dilute with 4 to 10 parts of water. 

Cocain muriate, 
Chloral hydrate, 

Resorcinol aa 1.0 

Glycerin 3.0 

Alcohol 20.0 

Aq. lauro-cerasi 30.0 

Water 44.0 



728 APPENDIX 

Ointments. — The application of a fatty substance on a pruritic 
region sometimes suffices to bring considerable relief to the patient; 
fresh lard, cerate or pure vaseline may serve for this purpose; the 
preference is often accorded to sapolan, naphtalan, pure cod-liver 
oil, in compound salves, or better in the form of collosol. 

Needless to say, it is often very advantageous to incorporate one 
or several of the antipruritic substances with the salves or pastes. 
Tse is frequently made of starch glycerite with tartaric acid (5: 100), 
or a mentholated oil with chloroform (camphorated oil of chamomile, 
100, chloroform 2 to 5, menthol 1.) 

Ethyl para-amido-benzoate (anesthesine or benzocaine of Poulenc) 
is employed (10 to 30 : 100) in a lanolin cream mixed with alcohol or 
olive oil (10 to 30 : 100) ; or also in a mucilage of gum Arabic. Ortho- 
form (orihocaine) should be rejected on account of the severe erup- 
tions and intoxications which it may cause. 



SALVE. 

Menthol 1.0 

Chloral hydrate, 

Camphor aa 5.0 

Lanolin 35.0 

Vaselin 50.0 

PASTE. 

Menthol 0.5 

Phenol 1.0 

Salicylic acid 2.0 

Tumenol 5.0 

Lassar's paste 90.0 

COD-LIVER OIL SALVE. 

Cod-liver oil 5.0 to 30.0 

Olive oil 5.0 to 25.0 

White wax 5.0 

Paraffin 8.0 

Aq. rosae, 

Aq. lauro-cerasi . aa 10.0 

Occlusive Dressings. — Undoubtedly the mere fact of protecting 
the diseased surfaces from the air represents a valuable measure for 
the control of pruritus. Salves and pastes evidently owe to this a 
considerable share of their efficiency. Poultices with starch, moist 
dressings and properly applied cotton wraps likewise secure good 
occlusion, provided the affected surfaces are not too extensive. 
"Zinc gelatin," which is applicable to large surfaces, if desired, is 
still more practical; here follows the fundamental formula and a 
modified formula so as to render the gelatin harder in the warm 
season of the year: 

Gelatin 15 or 30 gr. 

Zinc oxide 15 or 10 gr. 

Glycerin 25 or 30 gr. 

Water 45 or 30 gr. 



ANTIPRURITIC AGENTS AND LOCAL ANESTHETICS 729 

The mass is liquefied in the water-bath, applied with a flat brush, 
then while the coating is still viscid, the surface is dusted with ab- 
sorbent cotton which adheres to it and gives it the appearance of 
swan-skin. A zinc-gelatin covering may be left in place for several 
days; it is removed by stripping or by means of warm water. 

With this zinc-gelatin, ichthyol or other active substances may be 
incorporated; it is preferable to apply these substances by painting 
them on first, after which the surface is covered with the gelatin. 

Varnishes and Plasters. — The entire series of tars and analogous 
substances may serve as a siccative coating, either in the natural 
state (coal-tar, vegetable-tar, ichthyol, thiol, tumenol, thigenol, etc.), 
or in the form of extracts, or ether and alcoholic or various other 
solutions. 

The ordinary plasters can nearly all be utilized for the treatment 
of localized pruritus. For this purpose, use is made especially of 
zinc oxide plaster, resorcinol or phenol plaster, red oxide, or cod- 
liver-oil plaster, etc. 

When treating pruritus and prurigo by topical medication, one 
must never omit adding advice concerning hygiene, hydrotherapy, 
the employment of electricity under various forms, hot air, hyper- 
tonic sera, etc. 

Local Anesthesia. 

This is very exceptionally indicated in the cutaneous neuralgias 
or dermatalgias (zona, herpes, etc.); in such cases, hot poultices, 
or ichthyol, guaiacol, carbolized and other solutions indicated above 
and painted on, are usually sufficient. 

To spare the patient the pain of certain small operations such 
as scrapings, scarifications, rather extensive biopsies (tuberculosis 
verrucosa, lupus, proliferations, tumors), there are several methods. 
The quickest is freezing with a jet of ethyl chloride, which has 
replaced the bag of salted ice, stypage with methyl chloride, etc. 
Much more complete and durable is anesthesia by injection of a 
solution of cocaine chlorhydrate (| to 2 : 100) locally or along the 
course of the regional nerves (fingers, penis, etc.), the patient must 
have eaten and be in the recumbent position; it is advisable not to 
exceed the dose of 0.02 at the head, 0.05 elsewhere. The addi- 
tion of a few drops of adrenalin or of carbolic acid (chlorhydrate 
of cocaine 2, phenol cryst. 0.50 to 1.0, water 100) favors anesthesia; 
Schleich in his infiltration method showed that very weak concen- 
trations are sufficient (chlorhydrate of cocaine, 0.10 to 0.20, sodium 
chloride 0.20, water 100). Less toxic than cocaine are allocaine, 
stovaine, etc.; I usually employ a solution of novocaine to which 
adrenalin is added just before use (novocaine 0.50 or 1.0, water 



7: 10 APPENDIX 

100, adrenalin „'„,], 10.0 to 25.0). It is essential after injecting 
analgesic agents to wait at least fifteen or twenty minutes before 
operating. 

Bonin's mixture (chlorhydrate of cocaine, menthol, carbolic acid, 
aa equal parts) is very efficient when painted over mucous mem- 
branes, ulcers and excoriated surfaces. 

5. CLEANSING AND KERATOLYTIC AGENTS. 

This group of therapeutic agents is applicable to the scaly or 
crusted dermatoses and to the keratoses. 

Baths. — To cleanse large surfaces, soapy baths may be utilized 
or alkaline baths (sodium carbonate 60 to 250 gr.) or sulphurous 
baths (hepar sulphuris 60 to 100 gr.). Vapor baths and dry air baths, 
at 70° or 80° (160°-175° F.) or over, act also through the sweating 
produced by them. 

Lotions. — Any soap with a soda base may be used for soapy washes. 
In city practice, patients prefer a prescription of some medicated 
soap; ichthyol, lanolin, salicylic acid, tar, sulphur, naphthol soaps, 
etc., are the most commonly used. 

Potash soaps, which are soft, are more keratolytic than soda 
soaps. Black soft soap is uninviting; but a white odorless potash 
soap can be made. 

The alkalimetric titration of the commercial soaps varies in con- 
siderable proportions. It may prove advantageous to render them 
less irritating by transforming them into super-fatted soaps. 

WHITE POTASH SOAP (VICARK)). 

Cocoanut oil 200 . 

Caustic potash, c.p 70.0 

Water 600.0 

Saponify hot and boil down to 500. To make this soap super-fatted, add stearin 
and water, aa 20, to each 100. 

LIQUID SUPERFATTED SOAP (FOR SURGICAL USE). 

Green soap, 

Castile soap aa 20 . 

Olive oil 17.0 

Oil of geranium or lemon q. s. 

Water 1000.0 

Filter. 

A decoction of quillaya (50 : 1000), quillaya extract and saponine 
are preferable to soaps for the cleansing of the scalp. 

Gentle rubbing with a wad of absorbent cotton moistened with 
alcohol, ether, or better with benzine, very efficiently cleanses the 
skin. 



CLEANSING AND KERATOLYTIC AGENTS 73 1 

An excellent measure for cleansing a cutaneous surface covered 
with crusts and scales consists in applying moist dressings or a 
poultice during several hours. 

Ointments. — A simple application of vaseline, almond oil, lard, 
starch glycerite, a stearate such as diadermine, etc., often suffices 
for the softening and detachment of the scales. For the scalp, beef 
marrow or mixtures of fats are in favor, such as: 

Cocoa butyr 30 

Almond oil 70 

01. rosse gtt. i 

It is sometimes advantageous to make inunctions with a soapy 
foam which is allowed to dry upon the skin (kerosis, acne). Soapy 
ointments are very practical and can be employed on the scalp, on 
account of the facility of cleansing with a wad of cotton moistened in 
water. 

SOAPY SALVE. 
Powd. soap, 

Lard aa 40.0 

Almond oil 20.0 

01. geranii gtt. iv 

Heat the fats to 150° C. (302° F.) before introducing the soap powder. 

SOAP SALVE (CARLE AND BOTTLED). 

Lard 50.0 

Potash 17.5 

Water 300.0 

Alcohol 10.0 

Lanolin 20.0 

Boil down to 120. 

With these salves may be incorporated a large number of the 
usual medicinal substances, notably sulphur, but not bodies which 
are incompatible with alkalis, such as pyrogallol, chrysarobin, acids 
in general, mercurial salts, etc. 

Soft soap in inunctions has a very powerful cleansing action (lupus 
erythematodes , pityriasis versicolor) ; but it is very irritating and its 
effects must be watched. 

Salicylic acid is the keratolytic agent par excellence. In weak 
dosage (1 : 100), it figures in many pastes or salves as a mordant 
and antipruritic agent; in stronger dosage (5 : 100) in vaseline, it 
constitutes the most habitually used detersive agent (psoriasis, 
ichthyosis, keratosis pilaris); in benzoinated lard and castor oil 
(5 : 200), especially when immediately covered with an imper- 
meable tissue, or in the form of an ointment or varnish, it displays 
its maximum activity (keratoderma, circumscribed hyperkeratoses). 

Acetic acid and lactic acid also have a keratolytic action. 



732 APPENDIX 

Resorcinol, which in weak doses acts as a keratoplasty agent, is on 
the contrary in strong doses (5 to 50 : 100) an excellent detersive 
and even exfoliating agent. The last named property is utilized 
in the following preparations which are destined to serve for exfoli- 
ation cures {acne, kerosis, flat warts, pigmentations). Resorcine may 
be combined with soft soap. 

MIXTURE FOR FLAT WARTS. 
Arctic acid (glacial), 

Lactic acid aa 10.0 

Precipitated sulphur 20.0 

Glycerin 40.0 

Apply cautiously; an analogous mixture may he made with ac. salicyl. or with 
phenol. 

KERATOLYTIC SALVE FOR SEVERE ACNE OF TRUNK (BROCQ). 

Resorcinol, 

Camphor aa 10.0 

Potash soap 15.0 

Precipitated sulphur 30.0 

Creta prep 5.0 

Vaselin 30.0 

Apply for five, then ten, then fifteen minutes before a hath. 

EXFOLIATING PASTE. 

Resorcinol 40.0 

Zinc oxide 10.0 

Kaolin 5.0 

Benzoated lard 25.0 

Unna [modified]. 

EXFOLIATING MIXTURE. 

Resorcinol 20.0 to 30.0 

Potash soap, 

Sulphur aa 20.0 

Spts. lavandulse 30.0 to 40.0 

Plasters and Varnishes. — In the case of circumscribed keratoses and 
verrucosities, potash soap plasters, and especially salicylated plasters, 
render excellent service. Collodium is also frequently employed. 

COLLODIUM FOR CORNS. 

Collodii flex 10.0 

Absolute alcohol 6.0 

Ether, sulph 4.0 

Salicyl. acid 2.0 

Ext. canabis Indica 1.0 

COLLODION FOR PAPILLARY WARTS. 

Collodii flex 10.0 

Absolute alcohol 6.0 

Ether sulph 4.0 

Ac. salicyl 2.0 

A(". lactic , . 1.0 



BLEACHING AGENTS 733 



6. BLEACHING AGENTS. 

Bleaching agents are employed in the treatment of hyperchromias, 
ephelides, chloasma, etc., and of hypertrichosis of the face in women. 

Lotions (washes). — Vinegar may be utilized, or weak solutions of 
hydrochloric acid (1 to 2 : 500), lemon juice, also watery or alcoholic 
watery solutions of sublimate (1 to 2 : 500), etc. 

For hairs of the face, reliance can be placed only on applications 
of peroxide water repeated several times daily, or on the peroxide 
cream a prescription for which follows: 

LOTIONS FOR CHLOASMA. 

Hydrarg. bichlorid 1.0 

Alcohol q. s. 

Plumbi acetat., 

Zinci sulphat aa 2.0 

Aq. distillata 250.0 

(Hardy.) 
Hydrarg. bichlorid., 

Ammonii chlorid aa 0.1 

Emulsion of almonds 100.0 

(Brocq.) 
In this formula, tinct. benzoin 5.0 may be substituted for the ammon. chlorid. 

The applications must be made in the morning and again in the 
evening; during the night, salves or ointments are applied. 

Ointments. — Creams, pastes and salves which contain sufficiently 
strong proportions of hydrogen peroxide, acetic acid, mercurial salts, 
or sulphur and naphthol, possess a more or less strong bleaching 
action. 

PEROXIDE CREAM 

Hydrogen peroxide water , . . . . 15.0 

Vaselin 10.0 

Lanolin 5.0 

Oxide of zinc 1.0 

Bichloride of mercury .., 0.5 

F. hebra's SALVE. 
Calomel, 

Bismuth subnitr aa 6.0 

Lard or vaselin 90.0 

The most energetic treatment of pigmentations consists in the 
employment of exfoliation by means of strong resorcin pastes or 
mixtures [but they have only a temporary effect]. 

Plasters. — Mercurial, carbojized mercurial and red plaster are 
useful. 



734 APPENDIX 

Whatever remedy has been employed, the treatment must be 
interrupted for a few days as soon as the skin becomes reddened and 
inflamed; the irritation should be soothed by means of a cream, or 
a starch glycerite with an addition of bismuth carbonate and kaolin 
(aa20 : 100). 

7. REDUCING AGENTS. 

Under this name we include a series of extremely valuable derma- 
tological remedies which have the common feature of being more or 
less avid of oxygen. This property, according to Unna, accounts for 
their biological action. 

Weak reducing agents, or even strong reducing agents employed 
in weak dosage or for a short time, are keratoplastic, antiseptic, 
relieve congestion and itching. Strong reducing agents are exfoli- 
ating, highly irritative and give rise to severe epidermo-dermatitis. 

Judging from my experience, in conformity with that of Jadassohn, 
the progressive order of activity of the usual reducing agents is 
apparently as follows: mercurial salts, resorcinol, sulphur and sul- 
phur-containing remedies, tars (ichthyol, thiol, tumenol, coal-tar, 
wood-tar, oil of birch, oil of cade); the most energetic are undoubt- 
edly pyrogallol and chrysarobin. 

The therapeutic investigation of a large series of derivates of 
these substances, which have been extolled as less toxic and less 
irritative, has been carried out only outside of France and not 
always with the necessary thoroughness and disinterestedness. It 
is useful to know the names of some of these: lenigallol or tripyrate 
(tri-acetate of pyrogallol), eugallol or mono-pyrate (mono-acetate), 
saligallol (disalicylate) ; gallanol, eurobine or trichrysate (triacetate 
of chrysarobine), etc. 

Reducing agents are employed under the most varied forms in 
kerosis and its complications, in the dry psoriatiform and lichenoid 
eczemas, in 2)soriasis, in the parakeratoses in general, in the lichens, 
etc. 

In the choice of excipients and combinations, the fact must be kept 
in mind that the wood-tars (of pine, juniper; or cade oil, etc.), have 
an acid reaction, whereas mineral or coal-tar is alkaline. 

Watery Lotions. — Ichthyol (sulpho-ichthyolate of ammonium) and 
thigenol are the only tars soluble in water. In order to render the 
other tars miscible with water, they must be emulsified with the 
assistance of saponine (saponined coal-tar) or in certain excipients 
such as retinol (a product of dry distillation of colophane); the 
opalol of Caillat and the collosol of Pepin are neutral soaps in which 
various tars can be emulsified; their use is clean and very con- 
venient. The tars are also incorporated into solid soaps (ichthyol 
soap, tar soap, cade oil soap, etc.). 



REDUCING AGENTS 735 

Sulphur is rarely employed dissolved; in carbon bisulphide, etc., 
it is dangerous; a very active commercial solution comes in cedar oil, 
known as denisol (7 per cent, of sulphur). The general preference 
is to employ sulphur either in suspension or in the colloidal state 
(denisoline), in lotions, either in the state of sulphides, or in soaps 
(sulphur soaps, sulphur-naphthol soaps). 

The following two prescriptions are of every-day use: 

CAMPHORATED SULPHUR LOTION (KEROSIS, ACNE, ROSACEA, 
ECZEMATIDES) . 

Precipitated sulphur 10.0 

Spts. of camphor 20.0 

Glycerin 5.0 

Rose water, 

Water aa q. s. ad 100.0 

SULPHUR LOTION (PITYRIASIS CAPITIS, SEBORRHEA) . 

Potassium sulphuret 2 . to 4 . 

Water 100.0 

Or preferably: 

Potass, sulphuret. liquid, 30 to 100 drops to a i glass of hot water. 

[The following is a useful modification of the well-known 

LOTIO ALBA (ACNE, KEROSIS, ETC.). 

Solution sat. zinci sulphatis, 

Solution sat. potassii sulphuretti aa 50 . 

Spts. odorati , 10.0 

To this mixture, beta naphthol 0.5, or resorcinol 2.0, or some- 
times glycerin 10.0, may be added.] 

Soluble mercurial salts may also serve in lotions: 

ACID MERCURIAL LOTION (ACNE) . 

Hydrarg. bichlorid 0.2 

Ac. acetic 1.0 

Tct. benzoin 5.0 

Kaolin 5.0 

Alcohol 20.0 

Aquai 70.0 

MERCURIAL LOTION FOR THE SCALP. 

Hydrarg. bichlorid 0.2 

Ammonii chlorid (or resorcinol or chloral hydrate) . . . . 1.0 

Aq. lauro-cerasi ■. 10.0 

Water • 90.0 

Moist Dressings. — Under this form I have employed only resorcinol 
(0.25 to 1 : 100) and especially ichthyol (2 to 10 : 100), with favor- 
able results. 



736 APPENDIX 

Baths. — There is no advantage in the employment of reducing 
agents in the form of baths. However, sulphur baths (hepar 
sulphuris 50.0 to 100.0) and the so-called Bareges baths enjoy a 
classical reputation. 

bareges' bath. 

Sodium monosulphide 60.0 

Sodium chloride (dry) 60.0 

Sodium carbonate 30.0 

For one bath. 

TAR BATH (BALZER). 

Oil of cade 50 to 100.0 

Fl. extr. quillaya 10.0 

Yolk of one egg, 

Water 250.0 

For one bath. 



Alcoholic and Ethereal Lotions. — Washes of this kind are applicable 
in the treatment of kerotic affections of the hairless skin (seborrhea, 
acne) or more especially of analogous affections of the hairy scalp. 
When the scalp is very dry, castor oil (1 to 5 : 100) may be added to 
the alcoholic lotions. The prescriptions here given as examples 
may be combined in a variety of ways with stimulating mixtures. 

LOTIONS FOR THE SCALP (PITYRIASIS, KEROTIC ALOPECIA). 

1. Beta-naphthol 0.10 

Hydrarg. bichlorid . 20 

Resorcinol, 

Amnion, chloride, 

( 'liloral hydrat aa 0.5 

Spts. lavandulse 100.0 

2. Hydrarg. bichlor 0.10 

Ac. salicyl 0.20 

Liq. carbonis deterg. 

Spts. sether., 

Spts. rosmarini aa, 15.0 

Spts. vini 55.0 

3. 01. Rusci, 

01. cadini aa 1.0 

Tct. quillaya: 20.0 

Alcohol (60 per cent.) 80.0 

Ointments. — According to the degree and depth of action which it 
is desired to obtain, use is made of creams, pastes or salves. 

The creams are prepared with cold cream, cerate, vasolanoline, 
or starch glycerite, incorporating calomel (2 to 10 : 100), turpeth 
mineral, yellow oxide of jncrcury (2 to 5 : 100) or precipitated 
sulphur (2 to 30 : 100). 



REDUCING AGENTS 737 

In France, oil of cade is traditionally used in psoriasis in the form 
of glycerite: 

CADE OIL GLYCERITE. Mild . strong . 

01. cadini 15.0 50.0 

Saponis viridis or extr. quillaya (to emulsify) . . q. s. 5.0 

Glycerite of starch neutral 85.0 45.0 

01. caryophyl q. s. q. s. 

A glycerite can be transformed into a paste by adding to it kaolin 
and magnesium carbonate (aa 10 to 15 : 100) ; the glycerites have 
the advantage of permitting easy cleansing of the skin. 

Pastes are more active and more convenient to use; their con- 
stituents may vary practically indefinitely. The following pre- 
scriptions are commonly employed by me (figured or psoriasiform 
eczematides, lichenoid eczemas, etc.) : 

ICHTHYOL SULPHUR PASTE. 

Sulphur precip 3.0 

Ichthyol 5.0 

Resorcinol 1.0 

Zinci ox., 

Starch aa 8.0 

Petrolati, 

Lanolin aa 10.0 

TAR SULPHUR PASTE. eak . strong . 

Sulphur, precip 3.0 5.0 

01. cadini 5.0 10.0 

Ac. salicyl 1.0 1.0 

Resorcinol -. 1.0 1.0 

Zinci ox., 

Talci aa 20.0 18.0 

Petrolati 50.0 47.0 

The formulas of these pastes can be well-nigh indefinitely modified 
by changing the nature of the powders or the fats; by replacing the 
ichthyol and cade oil with birch oil or other tars, or with extracts 
several satisfactory types of which are on the market (oleocade, 
oxycade); by employing other forms of sulphur, or by introducing 
mercurial salts. It should be remembered that except in the case 
of cinnabar (red mercuric sulphide), the association of sulphur and 
mercurials produces a black sulphide. 

Salves are more particularly adapted to obstinate cases and to 
the treatment of certain regions. 

The reducing agent is customarily introduced in a dose of 5 : 100 
and the mordant (salicylic acid, resorcinol) in a dose of 1 : 100, but 
there are numerous exceptions. 

For the scalp (kerosis, pityriasis, seborrhea, psoriasis), Sabouraud 
considers sulphur and sulphur derivatives as especially adapted to 
the oily forms and cade oil or its substitutes to the scaly condi- 
47 



7: is APPENDIX 

tions. \ irginia cellar oil lias been shown by him to be capable of 
assisting or replacing cade oil, which bas a very unpleasant odor, 
in lotions or ointments. 



SALVES FOR THE SCALP AND BEARD. 

1. Sulphur precip., 

01. rusci aa 5.0 

Resorcinol 1.0 

Ongt. Sapon. (Section 5) 90.0 

2. 01. cedri 

01. cadini deodorisati aa 5.0 

Hydrarg. ox. flav. 

Resorcinol aa 1.0 

Petrolati, 

Lanolin aa 10.0 

(Sabouraud.) 

FOR THE FACE (PITYRIASIS, ECZEMATIDES) . 

1. Calomel, vap. parat., 

Tannin, alcoh. parat aa 3.0 

Vaselin 100.0 

2. Sulphur precipi, 
Cinnabar, 

Bals. Peruv aa 3.0 

Vaselin 100.0 

FOR THE BODY. COMPOUND SALVE (PSORIAM- . 
Pyrogallol, 
Ac. salicylic, 

Resorcinol aa 1.0 

Sulphur precip., 
01. rusci, 

Ol. cadini aa 2.0 

Vaselin, 
Lanolin, 
Adipis aa 20 to 2.5.0 

STRONG PYROGALLIC SALVE (OBSTINATE LICHENOID ECZEMA, 
PSORIATIFORM ECZEMATIDEs) . 

Pyrogalloli 6.0 

Ac. salicyl 3.0 

Picis liq., 

Ichthyol aa 20.0 

Cerati 50.0 

The employment of pyrogallol salves must be very closely watched 
on account of the poisoning threatened by this agent. I have found 
that ehrysarobin salves of very weak concentration il : 4(10 to 
1 : 300 in lard), which have been recommended on various sides 
(Jadassohn, Sabouraud) are practicable when properly prepared 
and cautiously employed in progressive doses (pityriasis rosea, 
eczematides). 



REDUCING AGENTS 739 

[dreuw's ointment (psoriasis, lichen simplex chronicus, 
keratoid eczemas, etc.). 

Ac. salicylic 10.0 

01. rusci, 

Chrysarobini aa 20.0 

fPetrolati 20.0 

■j 01. theobromat . 5.0 

[Saponis viridis 25.0 

(Modified.) An unscientific but powerful and effective reducing agent. To be 
used in courses of five days followed by a three- to five-day course of Lassar's paste.] 

Certain mixtures, although containing active substances in fairly 
strong dosage, are often admirably tolerated, even in acute attacks 
of eczema. Caution in their use is nevertheless indicated; after 
the cutaneous susceptibility of the patient has been tested by appli- 
cations of brief duration, they may be employed in permanent 
inunctions. 

COMPOUND BALSAM (MODIFIED DTJRET'S BALSAM). 

Resorcinol 2.0 

Menthol, 

Guaiacol • aa 5.0 

01. cadini, 

Sulphur ppti aa 15.0 

Picisliq 18.0 

Sodii boratis . .36.0 

Camphor, 

01. ricini aa 40 . 

Glycerini . . .54.0 

Aceton 80.0 

Lanolin 100.0 

laillier's salve (keratodermas). 

Sulphur ppti., 

01. cadini, 

Picis liquid, 

Saponis viridis . . . . aa 25 . 

CHAULMOOGRA SALVE (PRURIGO) . 

Chaulmoogra oil 5.0 

Sulphur 8.0 

Camphor 12.0 

Tar 15.0 

Vaselin 62 . 

Modified Baissade balsam. 

Paints and Varnishes. — It is sometimes advantageous to employ 
reducing agents by applying them with a brush and covering with a 
powder, a zinc paste or a varnish. This is a practical method of 
employing chrysarobin; the latter is also very conveniently used 
in the form of pomatum- or salve-sticks. 



740 APPENDIX 

Pyrogallol 5 to 10.0 

Ether sulph., 

Spts. vini rect aa 45.0 

Cover with a layer of zinc-paste. 

Chrysarobin 10.0 

Chloroform 90.0 

( 'over with traumaticin : 

Gutta-percha 10.0 

Chloroform 90.0 

CHRYSAROBIN SALVE-STICKS. 

Chrysarobin 10.0 

Petrolati 30.0 

Cerae 30.0 

Butyr. cacao 20.0 

Paraffini duri 10.0 

Incorporate the chrysarobin with the vaselin, melt the other ingredients and mix. 
Cool in cylindrical molds. 

Solutions of various tars, coal-tar as well as vegetable tars, may 
be prepared in alcohol-ether, or in benzol and acetone, applied with a 
brush and covered with a zinc paste. They are sometimes incor- 
porated with collodion. 

TINCTURE OF TAR (SACK). 

Coal tar 10.0 

Benzol 20.0 

Acetone 70.0 

Use unfiltered. 

OIL OF CADE COLLODION (LICHEN PLANUS). 

Collodii flex 15.0 

Alcohol absolut., 

Ether aa 4.0 

01. cadini 5.0 

Ol. rusci 1.0 

Dind (Lausanne) and Brocq have brought into vogue applica- 
tions of crude coal-tar previously washed to free it from the excess 
of alkali. 

The coal-tar is spread over the skin by means of a brush, allowed 
to dry, then dusted with talc powder; the application is touched up 
every day or every other day and the coating is allowed to act during 
four to eight days. Far from being as irritative as one might believe, 
coal-tar is as a ride readily tolerated under this form, even in cases 
of oozing eczema; in hospital practice, it advantageously replaces 
the compound balsams which are far more expensive. Unfortu- 
nately, coal-tar is not a definite product and its composition varies 
enormously, according to its source. 



CICATRIZING AND KERATO PLASTIC AGENTS 741 

Plasters. — In the form of plasters the reducing agents exert an 
energetic action. The most common are mercurial, resorcinol, oil 
of cade and tar plasters; it is noteworthy that pyrogallol and 
chrysarobin plasters are not well tolerated. 

8. CICATRIZING AND KERATOPLASTY AGENTS. 

A medicinal agent produces neither cicatrization nor epidermisa- 
tion; these are curative effects on the part of the organism. 

The physician's part is limited to: (1) protecting the cutaneous 
lesions against external irritants and against secondary infections; 
(2) putting them in the best possible condition for the fight against 
the microbes and for a proper repair; (3) accessorily, stimulating a 
sluggish repair-process. 

In this respect it is greatly to the interest of the dermatologist to 
take into consideration the experience of operating surgeons and 
proceed in conformity therewith. For a number of years there was 
a tendency to replace antiseptic methods by the aseptic treatment 
of simple wounds. In the course of the great war, it was soon recog- 
nized in case of primarily or secondarily infected wounds that the 
at first very popular painting with iodine as well as applications of 
peroxide water, ether, permanganate, etc., were inadequate and even 
injurious. 

Surgical "toilet", as timely and complete as possible, followed 
by progressive antisepsis, are favored at the present day. 

In cutaneous pathology, conditions are different from those 
obtaining in surgery. I shall endeavor to arrange the problems which 
arise under a small number of headings. 

Aseptic or Slightly Infected Lesions. — For admittedly clean surgical 
wounds, aseptic dressings are sufficient. Traumatic wounds, which 
are always infected or promptly liable to infection, burns, chemical 
dermatitis, etc., should be treated by one of the following measures: 

Moist dressings with weak antiseptic solutions, selecting the least 
irritating; the so-called cytophylactic solutions (§1) are especially to 
be recommended, such as that of Prof. Delbet (Acad, des Sciences 
and Acad, de Med., Sept., 1915). 

Very interesting in its principle, convenient and economical, is 
the mechanically antiseptic fixogen dressing, devised by Mouchet 
and Loudenot (Archiv. de Med et de Pharm. milit., Jan., 1917, p. 
97). It consists of a varnish, at first known as fixol, analogous but 
preferable to the various mastisols, aseptofix, etc.; it is employed by 
painting it on the wound or the lesion and its surroundings, without 
preliminary disinfection; it is not irritative, agglutinates microbes, 
opposes their entrance and firmly fixes the layers of aseptic gauze 
with which it is covered after a minute's drying. 



742 APPENDIX 

The paraffinizaticm of wounds and burns by fusible mixtures 
(ambrine) accomplishes a non-adherent isolation, which has the 
fault, however, of being impermeable to secretions. I have previ- 
ously stated that the dressing of burns and painful dermatitides 
with fixed oils to which essential oils have been added (gomenol oil, 
for example) or with compound oils known as pyroleol or phlyctol 
which are analgesic and aseptic, is preferable in my opinion. 

Infected Wounds and Ulcerations. — Progressive moist antiseptic 
dressings, the borated sodium hypochlorite solution of Carrel- 
Dakin (calcium chloride 200, sodium carbonate 100, sodium bicar- 
bonate 50, boric acid for neutralizing; the solution to be prepared 
extemporaneously) employed as a continuous local bath, has proved 
to be extremely valuable for the sterilization of war-wounds and is 
worthy of being likewise applied to the treatment of certain ulcers. 

Dressings with the polyvalent serum of Leclainche and Vallee 
(serum of horses which have been immunized against the germs of 
the various suppurations), by favoring phagocytosis and regener- 
ation of the anatomical constituents, accomplish both physiological 
antisepsis and cytophylaxis (Presse Medicale, April 2, 1917, p. 187). 

Progressive chemical disinfection can also be aimed at by the 
employment of various powders. Vincent's powder (§2) seems to me 
superior to iodoform and its analogues, to ectogen, etc. Calcium 
chloride in the natural state, arsenobenzol as a powder, etc., are 
customarily employed on ulcerations of mucous membranes; 
methylene-blue still has its adherents. 

Various antiseptic salves, the ingredients of which have been 
given above (see Sections 2 and 3), notably Reclus' salve, are also 
considered as assisting cicatrization. Colloid silver salve (10 : 100) 
is entitled to special mention. 

Rhagades chaps, cracks. — These are treated either by mild cauteri- 
zations, or by painting them with steresol, adhesol, Commandeur's 
balsam, or balsam of Peru. 

Sluggish Cicatrizations. — Cauterizations with silver nitrate, 
chromic acid, etc., will check exuberant granulations. Grafts are 
indicated on extensive granulating surfaces and promise a more 
flexible and less contracting cicatrix. 

In case of sluggish ulcers, recourse may be had either to strong- 
antiseptics, stimulants and mild caustics, or to styrax ointment 
and its analogues, as well as balsam of Peru. Occlusion by diachy- 
lon or medicated plasters, or by zinc-gelatin, is sometimes sufficient. 
Heliotherapy, light-baths, hot-air douches, high frequency currents, 
are sometimes of the greatest value. 



STIMULANTS AND RUBEFACIENTS 743 

It must not be neglected to place the affected limb in a suitable 
position and to order, according to the cases, either immobilization 
or on the other hand, systematic gymnastic exercises. 

9. STIMULANTS AND RUBEFACIENTS. 

These are employed in the passive erythemas, in hyperidrosis of the 
feet, in the alopecias, in lupus erythemafodes, etc. 

They are represented by alcohol, alcoholic preparations and 
tinctures, ether, chloroform, the volatile oils, camphor, mustard, 
iodine and the acids, which supply the basis of the majority of 
stimulating topical agents; the latter are almost invariably used 
in the form of liniments: 

Liniments. — for frost-bite, hyperidrosis, etc.: 

1 . Tinct. iodin (or tannin) 1 to 5 . 

Spts. camphor 100.0 

2. Spts.'terebenth. 3.0 

Spts. camphor 47.0 

Spts. saponat 50.0 

3. Aq. ammonia? fort 5.0 

Spts. camphor 15.0 

01. amygdal. dulc 80 . 

4. Ac. tannici, 
Resorcinol, 

Ichthyol aa 2.0 

Glycerini 10.0 

FOR STATIONARY LUPUS ERYTHEMATODES AND ALOPECIA. 

Phenolis, 

Tinct. iodi, 

Chloral hydrat aa 5.0 

Paint on the surface. 

FOR ALOPECIA AREATA . 

Ac. acetic glacial 1-0 

Chloral, hydrat 4.0 

Etheris sulph ..30.0 

Apply with gentle friction. 

FOR DIFFUSE ALOPECIA. 

1. Tinct. cantharidis 5.0 

Tinct. jaborandi, 

Spts. melissse aa 15.0 

Spts. odorati 65.0 

2. Aq. ammonia fort 2 to 5.0 

Liq. picis alkalini, 

Spts. camphor aa 15.0 

Alcohol, 60 per cent 70.0 

3 . Quininse muriat 10 

Tinct. jaborandi 20.0 

Spts. ajtheris 80.0 

01. verbense Q- s - 



744 APPENDIX 

The last mentioned stimulating lotions are applied on the scalp by 
means of a small so-called "lotion-brush." The formulas can be 
easily modified by incorporating into them, if indicated, one or 
other of the reducing agents in use for the hairy regions. 

10. ANTIPARASITICS. 

Vegetable Parasites. — The destruction of the epidermophytes is 
usually easy on the hairless skin (cf. pp. 519, 524, 520, 529, 531). 

All the detergent remedies and strong antiseptics may be utilized, 
such as soft soap, naphthol, phenol, mercurial salts in solutions or in 
strong salves. The present preference is for iodine treatment with 
the tincture (1 : 20 to 50) or in a vaseline salve (1 : 100) or for 
chrysarobine in weak salves (1 : 300 to 1 : 3000). [For epidermo- 
phytoses of the hands and feet, Whitfield's salve (ac. salicyl 1.0, 
ac. benzoic 2.0, adipis benz. 12.0) is especially to be recommended.] 

In case of tinea, chrysarobin salve-sticks may also be employed 
(chrysarobin 10 to 30 gr., yellow wax 20 to 40, adeps lana? 50) or 
according to the formula give above. 

The employment of chrysarobin on the head, in strong salves, 
or especially in plasters, requires great caution on account of the 
highly irritative action of this remedy on the conjunctiva^. 

After epilation (by .r-ray) it is advisable to rub the scalp with 
dilute tincture of iodine, or with carbolized glycerine (1 : 50). 

Animal Parasites. — Pediculosis. — According to the conditions 
of the environment and other factors a choice should be made 
between the following remedies: 

Powders. — Naphthaline mixed with talc (50 : 100) ; N. C. I. mixture 
of the British Army (naphthalene 96, creosote 2, iodoform2). 

Liquids for Washes, Sprays or Sachets. — Benzine, xylol, petroleum, 
turpentine oil (15 : 1000), camphorated oil (10 : 100), spirits of 
camphor, carbolized water (2 : 100), chloroform water; vinegar 
with sublimate (1 :500); parasiticide wash of the Hopital Saint- 
Louis (sublimate 1, spirits of turpentine 130, glycerine 170, cam- 
phorated alcohol 700); cresyl solutions (for example: paracresylol 
or sapocresol 30, almond soap 15, water 1000, Choay). 

Recently, various products derived from cresol have been recom- 
mended, as well as various volatile oils, for example: 

SOLUTION FOR SPRAYS. 

Anisol (methyl-phenol) 0.03 to 0.05 

Denatured alcohol, 

Water aa 50.0 

Kills lire in eight to ten minutes; to be employed several days in succession. 



antiparasitics 745 

PARASITICIDE MIXTURE (LEGROUX) . 
01. citronellae, 
01. menthse pip., 

01. eucalypti glob aa 300.0 

Naphtalin pulv 100.0 

To be used in "sachets," or in dilute alcoholic solution (5 to 100) as a wash. 

Disinfection of clothing and bedding in the steam-sterilizer is of 
great importance; shaving of the head and body hairs, when prac- 
ticable, as well as ironing the clothes with a hot iron, are to be 
recommended. 

Salves. — These may be prepared from a large number of the above- 
mentioned remedies. I repeat that I have found yellow mercury 
salve most efficient and harmless in the treatment of phthiriasis 
inguinalis (yellow oxide of the Hg. 10, oxide of zinc, 10, salicylic 
acid and resorcin aa 1, vaseline 78.) 

Scabies. — There is an abundance of formulas; the majority are 
based on sulphur. 

Balsam of Peru and styrax ointment are also excellent against 
the itch and may be employed pure or incorporated in vaseline, or 
dissolved in alcohol with an addition of castor oil. 

HOPITAL SAINT LOUIS FORMULA. 

Sulphur, sublimat 20.0 

Potass, carbonat 8.0 

Aq. destil 8.0 

Adipis 64.0 

HELMERICH-HARDY SALVE. 

Sulphuris nor 20.0 

Potass, carbonat 10.0 

120.0 



VLEMINCKX' SOLUTION. 

Sublimed sulphur 250.0 

Quicklime . . . 150.0 

Water 2500.0 

Boil down to 1500. 

WILKINSON-HEBRA SALVE. 
01. Rusci, 

Sulphur, sublimat aa 10.0 

Saponis viridis, 

Adipis aa 20.0 

Cretse pulv 5.0 

BOURGUIGNON'S SALVE. 

01. lavandulse, cinnamonii, 

Menthse pip., caryophyl '. . . . aa 2.0 

Tragacanth 4.0 

Potass, carbonat .30.0 

Flor. sulphur 90.0 

Glycerini 180.0 



746 APPENDIX 

PERU BALSAM SALVE. 

Bals. Peruv 15.0 

Styracis liq 20.0 

Cretse prsep 20.0 

Adipis (or petrolati) 45.0 

With the two last named salves, disinfection of the clothing is 

said to be not absolutely necessary but the bedding must be dis- 
infected. 

[Sherwell's method is simple and effective: The patient, stripped 
and in bed, rubs himself vigorously every night with the dry powder 
of flowers of sulphur (sulphur sublimatum), leaving the spilled 
powder between the sheets and under the night-clothes. The cure 
requires about a week. It has the merit, of simplicity and great 
economy, especially where an entire family has to be disinfected. 1 

11. CAUSTICS. 

The employment of caustics for the destruction of small tumors, 
proliferations and nevi, is becoming more and more restricted; the 
preference is accorded to the galvano-cautery, superheated air and 
carbonic acid snow, the action of which is instantaneous and more 
easily graduated. 

Use is still sometimes made, however, of the following: nitric, 
hydrochloric, lactic, trichloracetic, chromic, arsenious acids; caustic 
potash; zinc chloride, corrosive sublimate, acid nitrate of mercury, 
pure phenol, resorcin, pyrogallol, permanganate of potash, etc. 
Ordinary formalin has been recommended for the destruction of 
proliferations. 

Arsenious acid is the remedy of choice for epitheliomas, in suspen- 
sion in a liquid rather than in the form of a paste. 

CZERNY-TRUNECEK SOLUTION. 

Arsenic triox 1-0 

AquEe, 

Alcohol (90 per cent.) aa 50.0 

Shake. For method of use see p. 688. 

ARSENICAL POWDER. 

Arsenic triox 1.0 

Carbonis ligni pulv 2.0 

Hydrarg. sulph. rubri 5.0 

Mix with a little mucilage. 

canquoin's paste (carbuncle). 

Zinci chloridi 8.0 

Zinci oxidi 2.0 

Amyli tritici 6.0 

A«i. dest 1.0 

Make a paste. 



DIET 747 

VIENNA PASTE. 

Potassii hydrox 5.0 

Calcis ustse . 6.0 

Before use, make a paste by moistening with alcohol. 

Silver nitrate has only a very superficial action. It is often em- 
ployed in pencils or in watery or alcoholic solutions (1 : 10 to 30) 
on mucous patches, erosions and for the control of exuberant granu- 
lation of wounds. 

Its action can be considerably strengthened by the so-called 
"two pencil" procedure: the surface which has been cauterized with 
silver nitrate is passed over with a pointed pencil of metallic zinc. 
This procedure is serviceable for example in cases of ulcerated lupus. 

I have often advantageously utilized the following caustic pastes, 
advocated by Unna : 

GREEN PASTE (LUPUS VULGARIS). 

Antimonii trichlorid. 

Ac. salicylic aa 2.0 

Creosoti (Beechwood), 

Ext. cannabis Ind aa 4.0 

Lanolin 8.0 

WHITE CAUSTIC PASTE (TUBERCULOSIS VERRUCOSA). 

Caustic potash, 

Quicklime, 

Green soap, 

Distilled water aa 5.0 

Apply over the lupus or verrucous patch, by means of a spatula, 
a layer of paste about the thickness of a knife-blade; wipe off the 
edges with cotton; cover with a large piece of zinc oxide plaster. 
In case of the white paste, it is advisable to interpolate a wad of 
moist cotton between the caustic and the plaster. The pain is 
never excessive and does not last long. At the end of a few hours 
the plaster is removed and moist dressings are applied. In case of the 
green paste, the applications are repeated twice a week on an aver- 
age, until total destruction of the diseased tissue has been accom- 
plished. 

I have found these preparations preferable to cauterizations with 
pyrogallol, resorcin in strong salves, or potassium permanganate 
in concentrated solution or as a powder, which are employed by 
others. 

12. DIET. 

It would be altogether erroneous to assume that there is an 
alimentary regimen applicable to all cutaneous diseases. Nor is it 
a given eruption which governs the diet, but rather the general 



748 APPENDIX 

nutritional disturbance of which it may be a direct expression or an 
indirect consequence or which may create a predisposition to that 
particular eruption. 

In a patient suffering from a skin disease, the demonstration of 
diabetes, anemia, "lymphatic" constitution, gastro-intestinal dys- 
pepsia or enteritis, hepatic or renal insufficiency, nervousness, or 
an intoxication or chronic auto-intoxication, etc., necessitates in 
itself the appropriate diet, such as laid down in text-books of general 
medicine. 

Another point which must be thoroughly considered is the exist- 
ence of infinitely variable, practically unlimited and often entirely 
unexpected individual sensibilities and idiosyncrasies of intolerance 
toward many articles of food and drink. It is therefore advisable 
to make it a rule never to ignore the statements of patients in 
regard to their intolerance of a given alimentary substance; on the 
contrary, care should be taken to guide their observations in this 
direction, while realizing that persons capable of trustworthy self- 
observation are in a great minority, as pointed out by Jadassohn. 

All dermatologists have encountered patients who attribute their 
attacks of erythema, urticaria, pruritus or eczema, to the ingestion 
of strawberries, mussels, game, pork, or champagne; others hold 
milk, eggs, spinach, veal, etc., responsible. Although the available 
information on the subject of anaphylaxes is of a kind to furnish the 
explanation for a certain number of cases, the physician is justified 
in remaining unconvinced until a positive demonstration has been 
made. 

At an}' rate, it would be unreasonable and exaggerated to forbid 
to all patients what may have harmed a few; this would result in 
the prescribing of an over-rigid and more or less impracticable 
diet. 

The physician may sometimes find it necessary to recommend 
for a time an exclusive regimen such as an absolute milk diet, or 
a purely carbohydrate regimen, permitting only successively the 
addition of various kinds of foods and drinks; through this pro- 
cedure, which is logical and to be recommended, one may hope to 
trace the idiosyncrasy of the patient. It is always advisable in such 
cases to be on one's guard against unintentional departures from the 
regimen and against fraud. 

[Some knowledge of cookery is a very useful acquisition on the 
part of the physician. In excluding milk and eggs, for instance, it 
must be remembered that these articles enter into many prepara- 
tions of food, various sauces, most pastries, etc.] 

After these general statements, I am adding a list of the beverages 
and foods which are often found to be injurious to patients suffer- 
ing from hyperemic or pruritic dermatoses {erythemas, urticarias, 



DIET 749 

eczemas, neurodermatitis, lichen planus, etc.), and which it is 
customary to prohibit more or less strictly. 

Alcoholic beverages in general (especially unmixed wine, cham- 
pagne, liqueurs, bitters, medicated wines, strong beers, cider), as 
well as coffee, tea and chocolate. 

High meats and conserves (game, smoked meats, salted meats, 
sausages, meat-pies, ragouts, galantines, foie gras) ; certain meats, 
such as pork, duck, veal. 

Deep-sea fish, smoked or salted fish, crabs, lobsters and shellfish. 

Vegetables: Sorrel, spinach, tomatoes, stringbeans, asparagus, 
cabbage, cauliflower, "sour krout," cucumbers, mushrooms, 
truffles, raw salads. 

Fruits: Strawberries, raspberries, gooseberries, melons, nuts 
and figs. 

All cheeses, except fresh non-fermented and salted cheese. Sweet- 
meats and pastries. 

In a general way, all condiments, vinegar, spices, mayonnaise 
dressings, tartare sauces, mustard, etc. 

This list will be seen to comprise among others: (1) Substances 
possessing stimulating or irritative properties (alcohol, tea, coffee, 
spices) ; fermented, changed substances or those suspected of being 
so on account of their liability to change and containing toxins (high 
meats and venison, meat-conserves, deep-sea fish) ; foods of difficult 
digestion (salads, raw substances). 

It goes without saying that restrictions or prohibitions must be 
rendered with tactfulness and discrimination, adapting them not 
only to the pathological conditions of the case but up to a certain 
degree to the social standing of the patient. The diet must be 
individualized, like all therapeutic prescriptions. Suggestions in 
this respect may be drawn from the few general directions which I 
have summarized in discussing the treatment of eczema. 

[The divergence among competent dermatologists on so appar- 
ently simple a question as the value of a non-nitrogenous diet in 
psoriasis and some other dermatoses is certainly remarkable and 
suggestive. In regard to urticaria, oedema circumscriptum and 
similar affections which seem to be typical of an anaphylactic dis- 
turbance, how often does the most rigid inquest fail to disclose the 
peccant alimentary or autotoxic substance! The recently introduced 
"cutaneous tests" that in theory seemed so promising have proved 
disappointing in practice.] 

In conclusion, I consider it necessary to emphasize once again the 
importance, which I regard as very great, of ascertaining the con- 
dition of the teeth (notably in erythrosis, in many eczemas and 
pruriginous dermatoses, in alopecia, etc. Dental caries, or the loss 
of a large number of teeth, an abundance of tartar, pyorrhea alveo- 



750 .1 PPENDIX 

laris, inflammations of the gums or gingivitis are certainly the start- 
ing-point not only of reflex disturbances but also of a real chronic 
intoxication. The latter is the effect either of the constant swallow- 
ing of putrid products and pus, at all hours of the day and night; or 
of the arrival in the stomach of imperfectly masticated and poorly 
insalivated food; the latter, not being in a condition to undergo in 
a proper way the action of the digestive juices, will permit and favor 
abnormal gastro-intestinal fermentations. 

After having experienced it on repeated occasions, I am now 
convinced that putting the teeth in good condition, wearing a 
suitable artificial denture, with proper care of the mouth, can 
powerfully contribute to the inhibition of eruptive attacks, to the 
improvement of the general condition of many patients; while 
permitting the cure of skin diseases which had before resisted even 
correct topical applications as well as the prescription of a Draconian 
alimentary regimen. 



INDEX 



Abscess, miliary, of little children, 
Abscesses of axilla, tuberous, 544 
Acant holysis, 174 
Acanthosis, 64 

nigricans, 242 
Acarophobia, 482 
Achromia, 320 
Achromic nevi, 320 
Acne, bromide, 476 

cachecticorum, 385, 567 

cornea, 385 

decalvans, 385, 394 

frontalis, 391 

hypertrophica, 374, 385 

iodide, 475 

juvenilis, 385 

keloid, 391 

lupoid, 394 

medicinal, 390 

miliaris, 385 

necrotica, 391 

occupational, 390 

papularis, 386 

phlegmonous, 386 

pilaris, 391 

polymorphous, 386 

punctata, 386 

pustular, superficial, 386 

rodens, 391 

rosacea, 36, 385 

rosea, 36 

sebacea, 383, 385 

syphilitica, 385 

telangiectodes, 566 

treatment of, 388 

tuberosa, 386 

variohformis, 385, 391 

vulgaris, 385 
Acne, cornee. 403 

"sebacce," 209 
Acneiform eczema, 90 

lupus, 570 

peripilar syphilid es, 396 

syphilides, 398 

tuberculides, 564 
Acnes. 384 
Acnitis, 398, 567 
Acro-asphyxia, 36 



446 



Acrodermatitis atrophicans chronica , 
344 

continuous, 186, 216 
Acrokeratoma, 212 
Actinomyces, 599 
Actinomycosis, 270, 599 
Acute circumscribed edema, 49 
Addisonian melanodermas, 325 
Adeno-lymphocele, 364 
Adenoma sebaceum, 672 
Adenomata, 672 
Adenomatous nevi, 672 
Albinism, 320 
Alcoholic solutions, 714 
Aleppo boil, 648 
Alimentary eruptions, 479 
Allergy, 548 
Alopecia atrophicans, 393 

parrimaculata, 393 

pseudo-favic, 394 
Alopecias, 407 

achromatous, 413 

areata, 413 

cicatricial, 412 

circumscribed, 412 

coronarius, 413 

decalvans, 413, 414 

diffuse, 408 

of general disease, 411 

kerotic, 408 

non-cicatricial, 412 

pathological, 408 

pellicular, 409 

pityroid, 409 

premature, 409 

regional, 408 

seborrheic, 409 

senile, 409 

syphilitic, 411 

totalis, 413 

traumatic, 408 

treatment of, 415 

with fragile hairs, 413 
Alopecic favus, 421 
Anal pruritus, 488 
Anaphylaxis, 460 
Anatomical tubercle, 552 
Anesthetics, local, 729 
Anetoderma erythematosum of Jadas- 
sohn, 345 



752 



INDEX 



Angina, herpetic, 152 

Vincent's, 306 
Angiohematic typhus, 57 
Angiokeratoma, ol>4. tilt.") 
Angiokeratotic tuberculides, 5(34 
Angioma, 693 

flat, 693 

progressive multiple, 694 

senile, 695 

stellate, 695 

tuberous, 693 
Angiomatous Lupus, 554 
Angiosarcoma, 707 
Anidrosis, 442 
Annamite ulcers, 301 
Annular syphilide, 144 
Anonychia, 431 
Anthrax, 593 
Anti-anaphylaxis, 461 
Antiparasitics, 743 

for animal parasites, 744 

for pediculosis, 744 

for scabies, 745 

for vegetable parasites, 743 
Antiphlogistics, 718 
Antipruritic agents, 727 
Antipyrin bulla?, 177 
Antipyrinides, 473 
Antiseptics and astringents, 722 

strong, 726 
Aphtha?, 306 
Aplasia laminaris, 354 

moniliformis, 418 
Arciform syphilide, 144 
Argas, 514 
Argyria, 332 
Arsenical dyschromias, 328 

keratosis, 213 

treatment of, 661 
"Arthritide bulleuse," 179 
Arthritism, 479 
Arthropathic psoriasis, 105 
Artificial dermatitides, 447, 467 

eczema, 79 

pigmentations, 321 

pruritus, 482 
Aspergillus, 599 

lapidophyton, 528 
Atrophic dermatoses, 335 

lichen planus, 137 
Atrophies, cicatricial, 339 

cutaneous, 334 

idiopathic, 343 

linear, 341 

macular, 341, 345 

postsyphilitic, 342 

regional, 353 

reticular, 344 

round, 342 

sclerotic, in spots, 346 
Atrophoderma, 334 

pigmentosum, 355 



Autotoxic eruptions, 479 

erythemia, 28 

urticaria, 46 
Axilla, abscess of, tuberous, 544 



B 



Bai.axoposthitis, circinate erosive, 311 
Balsamic erythemas, 473 
Barlow's disease, 55 
Baso-cellular epithelioma, 679 
Bazin, acne pilaris of, 391 

erythema induratum of, 274 

pathogenic erythema of, 27 
Bazin's hydroa, 176 
Beard, eczema of, 74 
Beauty spots, 664 
Bed-bugs, 506 
Biett, collarette of, 626 
Biopsic pruritus, 487 
Birthmarks, 664 
Biskra boil, 648 

button, 250 
Black tongue, 229 
Blastomycoses, 603 

Busse-Buschke type of, 603 

Gilchrist type of, 603 
Blastomycosis, 270 
Bleaching agents, 733 
Blisters, 175 

Blood, diseases of, dyschromias in, 328 
Bockhardt, impetigo of, 167 
Body-lice, 504 

Boeck, acne necrotica of, 391 
Boils, 540 

Botryomycoma, 704 
Boubas, 650 

Bowen, precancerous dermatosis of, 236 
Brocq, lupoid sycosis of, 394 

pseudo-pelade of, 393 
Bromide acne, 476 
Bromidrosis, 443 
Bromoderma tuberosum, 476 
Bubo, syphilitic, 612 
Buccal cavity, neoplasms of, ulcerative, 
309 

diphtheria, 305 

gangrene, 308 

herpes, 304 

hydroa, 304 

ichthyosis, 219 

mucosa, erosions of, diphtheroid, 
304 
ulcerations of, 304 

pemphigus, 304 

pruritus, 488 

psoriasis, 219 

zona, 304 
Bulla?, 174 

acant holy tic, 174 

antipyrine, 177 



INDEX 



753 



Bulla?, deep, 174 

purulent, 174 

subcorneal, 174 

subepithelial, 174 

superficial, l74 

traumatic, 175 
Bullous dermatoses, 174 
accidentally, 175 

erythema, 24 

impetigos, 178 

polymorphous erythema, 175 

syphilides, 177, 620 

toxicodermas, 177 

urticaria, 45, 175 
Burns, 450 

of first degree, 451 

of second degree, 451 

of third degree, 451 
Buttock, herpes of, 153 



Cachetic ecthyma, 170 

purpura, 54 
Cachexias, dyschromias in, 328 
Cacotrophia folliculorum, 402 
Calcareous tumors, 692 
Calcified epithelioma, 679 
Callositas, 449 
Callus, 449 
Calvities, 408 

hippocratica, 409 
Calymmato-bacterium granulomatis, 

251 
Canaliculitis, 310 
Cancer, green, 653 
Cancers, epithelial, 676 
Cancroid epithelioma, 677 
Cancroids, 676 
Canities, 416 
Carafes, 528 
Carbolic gangrene, 314 
Carbunculus, 543 
Carcinoma, secondary, 683 
Carrion's disease, 593 
Caustics, 746 
Cellular nevi, 666 
Cervical zona, 156 
Chalazoderma, 372 
Chancre, dwarf, 615 

ecthymatous, 615 

extragenital, 616 

genital, 616 

giant, 615 

hard, 613 

hypertrophic, 615 

incipient, 597 . 

mature, 597 

miliary, 597 

mixed, 283 

papular, 597, 615 
4S 



Chancre redux, 615 

simple, 596 

soft, 281, 596 

extragenital, 282 

of genital mucosa, 316 

syphilitic, 613 

of genital mucosa, 311 
of mouth, 307 ■ 

ulcerative, 615 
syphilitic, 283 
Chancroid, 281, 596 
Chancroidal folliculitis, 597 

phagedena, 295 
Cheiropompholyx, 85 
Chilblains, 34 
Chloasma, 324 
Chloroma, 653 
Chlorotic pemphigus, 192 
Chromatorrhexis, 591 
Chromidroses, 444 
| Cicatrices, 336 
Cicatricial alopecias, 412 

atrophies, 339 

depilating folliculitides, 392 

epithelioma, flat, 681 

folliculitis of hairless parts, 566 
Cicatrizing and keratoplastic agents, 

740 
Circinate erosive balanoposthitis, 311 
Circumscribed alopecias, 412 

keratoses, 206 
Clavus, 449 

Cleansing and keratolytic agents, 730 
Cohnistreptothrix, 599 
Collarette, of Biett, 626 
Colloid milium, 359, 692 
Colored sweats, 444 
Comedo, 385 

Condyloma acuminatum, 238 
Congenital elephantiasis, 361, 370 

erythrodermas, 122 

hyperkeratosis, 203 
diffuse, 124 

ichthyosis, 124 

macroglossia, 370 

malformations of nails, 431 

malignant keratoma, diffuse, 124 

pemphigus, 191 

syphilis, 624 

precocious, 625 

xanthoma, 699 
Conjunctiva, herpes of, 153 
Connective-tissue tumors, 689 
Contusiform dermatitis, 265 
"Copper-nose," 374 
Corns, 449 

Cornu cutaneum, 677 
Corona veneris, 144 
Couperose, 36 
Crab-louse, 505 
"Crasse des vieillards," 209 
Creams, 717 



INDEX 



< Iretinism, 372 

( rvptococcus, 599 

( '\itis hvperelastica, 372 

laxa, 372 
( !ylindroma, 682 
( 'vstic follicular adenomatous nevi, 071 

sudoriparous adenomata, 672 
( Systicercus cellulosse, 515 
Cysts, 670 

dermoid, 671 

epidermic, 670 

traumatic, 671 

follicular, 671 

sebaceous, 670 

scnms, 672 



Darier's disease, 231 

Date-boil, 648 

Degeneration, senile, 357 

Delhi boil, 648 

Demodex folliculorum, 513 

Depapillated plaques of tongue, 304 

Dermatitides, artificial, 447, 467 

due to mechanical causes, 448 
physical causes, 450 

induced, 467 

occupational, 467 

simulated, 471 

traumatic eczematiform, SO 
Dermatitis, acute benign exfoliating, 
116 

artefaeta, 183 

atrophicans, 343 

contusiform, 265 

exfoliating, 117 

of nurslings, 123 

gangrenous, of children, 317 

generalized exfoliative, 117, US 

herpetiformis, 17(1 

papillaris capillitii, 391 

polymorphous, 179 

sycosiformis atrophicans, 394 

vacciniform, infantile, 168 

venenata, 470 
I termatolyses, 372 
1 )ermatomycoses, 599 

ulcerations of, 293 
Dermatophobia, 482 
Dermatophytes, 502 
Dermatoscleroses, 334, 353. 
I >ermatoses, atrophic, 335 

bulbous, 174 

accidentally, 175 

caused by acari (mites), 507 
by insects, 502 
by worms and larva?, 514 

dyschromic, 323 

eruptive, 17 

erythematous-squamous, 89 

erythrodermic, 120 



Dermatoses, hypertrophic, 361 

infectious, 535 

liacillary, 546 

chronic, pustules of, 172 

due to protozoa, 610 

of leukemias, 651 

nodular, 263 
acute, 265 

non-eruptive, IS 

nosology of, 447 

onychoses of, 434 

papillomatous, 238 

papular, 127 

parasitic, 502 

pigmentary, of legs, 323 

precancerous, of Bowen, 236 

proliferating, accidentally, 244 

pustular, 161 

sclerotic, 335 

tropical proliferating, 249 

tuberculo-ulcerative, 253 

ulcerative', 2S1 

vesicular, 149 
Dermic gummas, 267 

papules, 128 

pustules, 160 
Dermographism, 49 
Dermoid cysts, (571 
Desquamation of newborn, lamellar, 

122 
Desquamative erythema, 24 

erythroderma of nurslings, 124 
Diabetic eruptions, 480 

gangrene, 316 

xanthoma, 699 
Diabetides, genital, 480 
Diathetic pruritus, 484 
Diet, 747 
Diffuse congenital hyperkeratosis, 124 

malignant keratoma, 124 
Diphtheria, buccal, 305 

cutaneous, 594 
Diphtheroid erosions of buccal mucosa, 
304 

pemphigus, 187 

stomatitis, 305 
Discomyces minutissimus, 533 
Disseminated miliary lupoid, 259 

pigmentary spots, 325 
1 >racunculus, ."ill 
Dry eczema, 63, 72 

erosions of tongue, 304 
Duhring's disease, 17!) 

rare dermatoses related to, 184 
Dwarf chancre, 615 
Dyschromias, 320 

arsenical, 32S 
artificial, 321 

associated, 323 
in cachexias, 328 
diffuse, 325 



INDEX 



755 



Dyschromias in diseases of blood, 328 

of leprosy, 327 

of nervous diseases, 327 

secondary, 321 
Dyschromic dermatoses, 323 
Dyscratic pruritus, 484, 487 
Dysidrosis, 85 
Dysidrotic eczema, 86 
Dyskeratoses, 194, 230 

follicularis, 231 

lenticularis et discoides, 236 
Dystrophic onychoses, 437 

trichoses, 416 
Dystrophies, cutaneous, 355 
Dystrophy, papillary, 242 

pigmentary, 242 
le, 358 



E 



Ecchymoses, 52 
Ecthyma, 169, 284 

cachetic, 170 

gangrenous, 317 

scrofulous, 170 

syphilitic, 170 

terebrans, 171 

scrofulosorum, 568 
Ecthymatous chancre, 615 
Eczema, 60 
Eczema, acneiform, 90 

acute disseminated, 87 

artificial, 79 

of beard, 74 

between toes, 75 

corneal, 214 

dry, 63, 72 

dysidrotic, 86 

erysipeloid, 71 

exudative, 71 

of face, 75 

fissured, 71 

flanellaire, 92 

folliculorum, 396, 564 

of forearms, 75 

generalized, 120 

of hairy regions, 74 

of hands, 75 

hyperkeratotic, 64 

impetiginous, 64, 71, 72 

infantile, 65, 80 

infected, 64 

intertrigo, of infants, 75 

keratotic, 72, 214 

lamellar, 64 

of legs, 75 

lichenified, 71, 72 

lichenoid, 64 

marginatum, 74, 90 
of Hebra, 524 

microbic, 66 



Eczema of nails, 435 

of nipple, 75 

nummular, 72 

occupational, 65 

orbicular, 75 

orificial, 75 

papulo-vesicular, 72 

parasitic, 65 

paratraumatic, 66, 73 

pilaris, 379 

psoriasis, 104 

psoriatiform, 64 

rubrum, 64, 71 

of scalp, 74 

scrofulosorum, 147 

seborrheal, 63 

seborrhceicum, 90 

secondary, 87 

senile, 65 

solare, 65 

squamous, 64, 72 

traumatic, from scratching, 65 

treatment of, 77 

true, 83 

tylotic, 72 

varicose, 73 

vesicular, 71 

vulgare, 72 

of war wounds, 66, 73 

weeping, 63 

of wrists, 75 
Eczematides, 90 

erythrodermic, 95 

figured, 92 

follicular, 395 

peripilar, 95 

pityriasiform, 93 

psoriatiform, 95 
Eczematization, 60 
! Eczematoid tuberculides, 564 
Eczematosis, 60, 83 * 
Edema, acute circumscribed, 49 

malignant, 594 
Edematous scleroderma, 347 
Elastoma, 359 
Elastorrhexis, 359 
Electric erythema, 32 
Elephantiasis, 361 

arabum, 361 

congenital, 361, 370 

filarial, 361, 369, 515 

grsecorum, 361, 578 

nostras, 361, 367 

papillomatous, 246 

secondary, 361, 368 

verrucous, 246 
Elephantiastic lupus, 554 
Emotional erythema, 28 

roseola, 25 
Endodermophytons, 528 
Ephelides, 323 
Ephidrosis, 443 



756 



INDEX 



Epidermic cysts, 670 

traumatic, 671 

nail, 431 

papules, 127 

pemphigus of newborn, 168 

pustules, 161 
Epidermolysis hereditaria bullosa, 
Epidermomycoses, 515 
Epidermophytes, 515 
Epidermophytosis, 114, 216, 522 
Epiphenomena, 175 
EpitheUal cancers, 676 

tumors, 669 
Epithelioma, 676 

baso-eellular, 679 

of buccal cavity, 309 

calcified, 679 

cancroid, 677 

cellular, 676 

flat cicatricial, 338, 681 

metastatic, 683 

nevo-cellular, 682 

pagetoid, 681 

papillary, 677 

papillomatous, 249 

proliferating, 249 

spinocellular, 676 

terebrans, 682 

treatment of, 687 

tubular, 679 

proliferative, 682 
Epitheliomatosis pigmentosa, 355 
Epizoa, 502 
Equine scabies, 120 
Ergotism, 316 
Erosions of tongue, 304 
Erosive ulcers, 676 
Eruptions, alimentary, 479 

autotoxic, 479 

diabetic, 480 

feigned^ 471 

medicinal, 463, 472 

serum, 477 

toxic, 472 
Eruptive dermatoses, 17 

xanthoma, 698 
Erysipelas, gangrenous, 319 
Erysipeloid eczema, 71 
Erythema, 23 

active, 24 

of alimentary origin, 27 

annulare, 26 

associated, 23 

atrophicans, 343 

autotoxic, 28 

balsamic, 473 

bullous, 24 

centrifugum, 570, 571 

desquamative, 24 

emotional, 28 

figured, 25 

a i'rigore, 27 



Erythema induratum, 564 
of Bazin, 274 
of young girls, 25 

infantile gluteal. 31 

infectious, 27, 28 

intertrigo, 27 
191 marginatum, 26 

multiforme, 39 

nodosum, 265 

nodular, 24 

papular, 24 

papulo-erythematous, 39 

papulo-lenticular, 31 

passive, 24 

in patches, 25 

pathogenic, of Bazin, 27 

pellagrous, 32 

pernio, 34 

perstans, 26, 572 

pigmented, 24 

polymorphous, bullous, 175 

a, pudore, 28 

purpuric, 24 

recurrent desquamative scarlatini- 
form, 25, 116 

reflex, 28 

rubeoliform, 25 

scarlatiniform, 25 

scarlatinoid, 25 

simple, 24 

solare seu actinicum, 32 

squamous, 24 

treatment of, 426 

urticarial, 24 

vesicular, 24 
Erythemato-atrophic tuberculides, 564 
Erythemato-follicular lupus, 570 
Erythemato-papular syphilides, 142 
Erythemato-squamous dermatoses, 89 
Erythemato-squamous epidermo-my- 

coses, 114 
Erythemato-tuberculous lupus, 555 
Erythematoid lupus, 228, 554 
Erythematous syphilides, 620 

tuberculides, 564 
Erythrasma, 114, 532 
Erythroderma, ichthyosiform, 203 
Erythrodermas, 23, 115 

congenital, 122 

desquamative, of nurslings, 124 

leukemic, 119 

of newborn, 122 

premycotic, 119 

primary, 116, 117, 118 

secondary, 120 
Erythrodermic dermatoses, 120 

eczematides, 95 

tuberculides, 564 
Erythromelia, 344 
Erythrosis facialis, 37 
Espundia, 650 
Esthiomene, 311 



INDEX 



757 



Ethereal solutions, 714 
Excoriation of tongue, chronic super- 
ficial, 229 
Exfoliative areata, 228 

dermatitis of nurslings, 123 
Extragenital chancre, 282, 616 
Exudative eczema, 71 



Face, eczema of, 75 

herpes of, 153 
Facial hemiatrophy, 354 
Fades leonina, 583 
Factitious urticaria, 49 
Farcy, 591 
Fatty bodies, 716 
Favus, 420, 516 

alopecic, 421 

cutaneous, 114 

of glabrous skin, 518 

impetiginous, 421 

of nails, 518 

pityriasic, 421 

squamous, 420 

treatment of, 426 

urceolaris, 420 
Feigned eruptions, 471 
Fetal ichthyosis, 124 
Fetus, harlequin, 124 
Fibroma, 689 

molluscum, 667 
Figured eczematides, 92 
Filaria medinensis, 514 
Filarial elephantiasis, 361, 369, 515 
Filariasis, 369 
Fissured eczema, 66 
Flat angiomas, 693 

senile warts, 208 

vascular nevi, 693 

warts, 127 
Fleas, 506 

Flores unguium, 438 
Fluxus sebaceus, 384 
Follicles, pilo-sebaceous, 376 
Folliclis, 398, 566 
Follicular cysts, 671 

eczematides, 395 

ichthyosis, 403 

keratosis, 401, 403 

pustules, 160 

syphilides, 396 

tuberculides, 398 
Folliculite conglomeree en placards, 382 

epilante, 394 
Folliculitides, acute suppurative, 377 

cicatricial depilating, 392 

subacute, 395 

trichophytic, 380 
Folliculitis agminata, 382, 522 

chancroidal, 597 

decalvans, 394 



Folliculitis rubra, 402 
Folliculoses, 376, 377 
Forearms, eczema of, 75 
Fox, Tilbury, impetigo of, 162 
Frambesia Brasiliana, 650 

tropica, 250, 646 
Freckles, 323 

infective melanotic, 665 
Frontal scleroderma, 351 
Frost-bite, 34, 452, 564 

of first degree, 34 

of second degree, 34 
Fungoid tuberculosis, 552 
Furfuracea, 409 
Furunculus, 540 

orientalis, 648 



Gafsa boil, 648 
Gangrene, buccal, 308 
carbolic, 314 
cutaneous, 312 
diabetic, 316 
direct local, 313 
dry, 312 

fulminating, of genital organs, 319 
moist, 312 

multiple, of adults, 318 
cachectic of skin, 317 
of children, 317 
through changes in blood, 316 
traumatic, 313 
of vascular origin, 315 
Gangrenous dermatitis of children, 317 
ecthyma, 317 
erysipelas, 319 
pemphigus, 187 
urticaria, 317 
varicella, 171, 317 
Gastro-intestinal purpura, 55 
Genital chancre, 616 
diabetides, 480 
herpes, 310 

mucosa, soft chancre of, 310 
syphilitic chancre of, 311 
traumatic excoriations of, 310 
tuberculous ulcer of, 311 
ulcerations of, 310 
organs, gangrene of, fulminating, 
319 
granuloma of, ulcerative, 251 
Genito-crural zona, 156 
Geographical tongue, 228 
Giant chancre, 615 

urticaria, 49 
Gift-spots, 438 
Glanders, 590 
acute, 591 
chronic, 592 
mutilating, of face, 592 



758 



INDEX 



Glanders, pustules of, 173 

ulcerations of, 293 
Glandular lymphadenoma, regional, 653 
Glossitis, deep, 226 

exfoliativa marginata, 228 

median rhomboidal, 226 

of nervous arthritics, 228 
• sclerotic, 226 

syphilitic. 225 
Glossodynia, 488 
Gluteal erythema, infantile, 31 
Glycerine, 715 
Glycosuric xanthoma, 699 
Gonococcal keratoderma, 216 

keratoma, 210 
Gonorrhea, erosions in, 310 
Gout, tophi of, 702 
Granuloma annulare, 261 

favosum, 517 

fungoides, 657 

of genital organs, ulcerative, 251 

inguinale, 251 

pyogenicum, 704 

trichophyticum, 522 

venereo, 251 
Granulosis rubra nasi, 443 
Green cancer, 653 
Groin ulceration, 251 
Ground-itch, 515 
Gummas, 266 

dermic, 267 

hypodermic, 267 

leprous, 272 

mycotic, 270 

scrofulo-tubercular, 268 

sporotrichotic, 270 

syphilitic, 267 

of palatine velum, 268 
of tongue, 268 

tuberculous, 268, 550 
Gummous infiltrations of leprosy, 272 
Gutta rosea, 36 



Haihy nevi, 668 

regions, pruritus of, 488 
Hamartoma, 359 
Hands, eczema of, 75 
Hang nails, 432 
Harlequin fetus, 124 
Head-lice, 502 
Heat-stroke, 32 
Hebra, acne varoliformis of, 391 

eczema marginatum of, 524 
Hebra's prurigo, 494 
Helconyxis, 437 
Hemangioma, 693 
Hematidrosis, 444 
Hematogenous pruritus, 485, 487 
Hemiatrophy, facial, 354 



Hemorrhagic pemphigus, 187 

urticaria, 44 

zona, 155 
Hemosiderin, 320 
Herpes, 150 

buccal, 152, 304 

circinatus, 66, 114, 522 

conjunctivalis, 153 

cretaceus, 570 

genital, 150, 310 

gestationis, 184, 185 

iris, 176 

malignant, 122 

of pharynx, 152 

progenitalis, 150 

recurrent, 153 

tonsurans maculosus, 93, 99 

ulcerated, 284 

vacciniform, 168 

zoster, 154. See Zona. 
Herpetic angina, 152 
Herpetide, benign, 122 
Herpetiform syphilides, 398 
Hidradenomata, 673 
Hidrocystoma, 672 
Hidrosadenitis, 446, 544 

suppurativa disseminata, 566 
Hidroses, 441 

functional, 442 

organic, 445 
Hutchinson's teeth, 628 
Hydradenitis destruens suppurativa, 

566 
Hydrargyria, cutaneous, 465 
Hydroa, 25, 175 

Bazin's, 176 

buccal, 177, 304 

herpetiforme, 179 

puerporum, 185 

vacciniforme, 185 
Hyperchromia, 320 
Hyperidrosis, 442 

nudorum, 443 

oleosa, 443 
Hyperkeratoses, 194 

congenital, 203 
diffuse, 124 

ichthyosiform, 124, 203 
Hyperkeratotic eczema, 64 

nevi, 206 

verrucose nevi, 667 
Hypertrichoses, 404 

fetalis, 406 

regional, 407 
Hypertrophic acne, 375 

chancre, 615 

dermatoses, 361 

lichen corneus, 140, 247 

mucous patches, 247 
Hypertrophies, cutaneous, 360 

non-elephantiastic, 371 
Hypodermic gummas, 267 



INDEX 



759 



Hypodermic sarcoids, 273 
tubercles, 252 
tuberculides, 564 



Ichthyosiform congenital erythro- 
derma with hyper-epidermatro- 
phy, 204 

erythroderma, 203 

hyperkeratosis, 124, 203, 205 
Ichthyosis, 200 

anserina scrofulosorum, 402 

buccal, 219 

congenital, 124 

cornea, 200 

fetal, 124 

follicularis, 403 

hystrix, 202 

nitida, 202 

sauriasis, 205 

senile, 202 

tabescentium, 202 
Idiopathic atrophies, 343, 344 

zona, 158 
Impetiginization, 64 
Impetiginous eczema, 64, 71, 72 

favus, 421 

lupus, 556 

onyxis, 434 

stomatitis, 167 
Impetigo, 162 

of Bockhardt, 167 

bullous, 168, 178 

contagiosa, 167 

figurata, 166 

granulata, 166 

herpetiformis, 185 

larvalis, 166 

miliary, 87 

of mucous membranes, 167 

sparsa, 166 

staphylococcic, 167 

streptococcic, 162 

of Tilbury Fox, 162 

vulgaris, 165 
Infantile eczema, 65, 80 

gluteal erythema, 31 

vacciniform dermatitis, 168 
Infected eczema, 64 
Infectious dermatoses, 535 
bacillary, 546 
due to protozoa, 610 

urticaria, 46 
Intercostal zona, 156 
Interstitial vesiculation, 148 
Intertrigo, 30 
Intertrigo-eczema, 30 

of infants, 75 
Intertrigo-erythema, 30 
Ioderma bullosum, 177 



Ioderma tuberosum, 476 
Iodide acne, 475 

pemphigus, 475 
Iris, herpes of, 176 
Isolation, 32 
Itching, 481 
Ixodes, 514 

J 

Jadassohn, anetoderma erythemato- 

sum of, 345 
Jigger, 506 
Juvenile flat warts, 130, 241 



" Kartenblattaehnliche morphoea," 

346 
Keloid acne, 391 
Keloids, 690 
Keratoderma, 195, 211 

essential, 211 

familial, 211 

gonococcal, 216 

occupational, 213 

symmetrical, of adults, 212 

symptomatic, 213 
Keratodermic syphilides, 619 
Keratoma, diffuse congenital malig- 
nant, 124 

gonococcal, 210 

palmare et plantare, 211 
Keratosis, 194 

arsenical, 213 

circumscribed, 195, 206 

diffuse, 195 

follicular, 401, 403 

generalized, 195 

of mucosae, 195 

of mucous membranes, 218 

pilaris rubra atrophicans of face, 
402 
simplex, 402 

punctiform, 216 

regional, 195 

senilis, 209 
Keratotic eczema, 72 

nevi, 206 
Kerion of Celsius, 382, 522 
Kerosis, 37, 196 
Kerotic alopecias, 408 
Koch's phenomenon, 548 
Koilonychia, 437 
Kraurosis vulvae, 354 



Lamellar desquamation of newborn, 
122 
eczema, 64 
Lanuginous pseudohypertrichosis, 406 



760 



1XDEX 



Larva migrans, 515 
Lazarine leprosy, 58(5 
Legs, eczema of, 75 

varicose ulcers of, 296 
Leishmanioses, 648 
Lenticular papular syphilides, 129, 142 

syphilides, til!) 
Lentigines, 665 
Lentiginosis profusa, 665 
Lentigo, 665 

maligna, 665 
Leontiasis, 365 

leprosa, 583 
Lepra maculosa, 585 

nervorum, 585 

tuberosum, 583 
Leprides, 581, 588 
Lepromas, 258 
Lepromata, 587 
Leprosy, 578 

dyschromias of, 327 

gummous infiltrations of, 272 

lazarine, 586 

mixed form of, 587 

morpha? of, 332 

"rat," 579 

tubercles of, 258 

tubercular, 583 

ulcerations of, 292 
Leprous gummas, 272 

infiltrations, 258 

morphea, 258 

nodosities, 271 
Leptothrix of Wilson, 428 
Leptus autumnalis, 513 
Leuconychia, 438, 653 
Leukemia, cutaneous, 651 

lymphatic, 651, 652 

myeloid, 651, 652 

treatment of, 661 
Leukemic erythroderma, 119 
Leukoderma, 321, 331 
Leukokeratosis, 219 
Leukomelanodermas, 331, 332 
Leukonychia totalis, 438 
Leukoplakia, 219 

and cancer, 221 

ulcerations of, 307 

vulvar, 220 
Leukotrichia, 416 
Lichen, acute, 134 

annulatus, 133 

serpiginosus, 90 

circumscriptus, 90 

corneus, hypertrophic, 140, 247 

ferox, polymorphous, 495 

gyratus, 90 

marginatus seu serpiginosus, 133 

nitidus, 564 

pilaris, 402 

planus, 131 
acute, 120 



Lichen planus, atrophic, 137, 332, 339 
moniliformis, 139 
of mucous membranes, 227 
nitidus, 138 
obtusus, 139 
sclerotic, 137 

scleroticus vel atrophicus, 463 
treatment of, 136 
verrucosus, 140 
psoriasis, 112 
rubra acuminatus, 399 
bullosus, 134 
planus, 131 
scrofulosorum, 145, 564 
simplex, 492, 498 
spinulosus, 403 
striatus, 133 
urticus, 492 
Wilson's, 131 
zoniformis, 133 
Lichenified eczema, 71, 72 
Lichenization, 490 
Lichenoid eczema, 64 
syphilides, 396 

trichophytosis, disseminated, 522 
tuberculide, 146, 564 
Linear atrophies, 341 

nevi, 206 
Lipoma, 691 
Livedo, 36 

annularis, 26, 36 
Liver spots, 664 
Lobular epithelioma, 676 
Lues venerea, 610 
Lumbo-abdominal zona, 156 
Lupoid acne, 394 

sycosis of Brocq, 394 
Lupoids, 272 
benign, 259 

disseminated miliary, 259 
nodular, 260 
tubercles, 259 
Lupoma, 553 
Lupus, 553 

acneiform, 570 
agminatus, 554 
angiomatous, 554 
colloid, 554 
confluens, 554 
diffusus, 554 
disseminatus, 554 
elephantiastic, 554 
elevatus, 554 
erythematodes, 228, 568 
discoides, 570 
disseminatus, 566 
exanthematicus, 564, 572 
migrans, 571 
treatment of, 573 
erythematoid, 554 
erythemato-follicular, 570 
erythemato-tuberculous, 555 



Index 



761 



Lupus exedens, 555 

hypertrophicus, 554 

impetiginous, 556 

macular, 554 

non-exedens, 554 

papillomatous, 554 

phagedenicus, 555 

planus, 554 

psoriatiform, 554 

pustular, 173, 555 

resolutus, 554 

scleroticus, 554 

serpiginous, 555 

squamous, 554 

treatment of, 561 

tubercle, 553 

tumidus, 554 

ulcerations, 290 

ulcerative vegetative, 555 

vorax, 555 

vulgaris, 553 
Lymphadenia, cutaneous, 657 
Lymphadenoma, regional glandular, 

653 
Lymphangiectases, 696 
Lymphangioma, 695 
Lymphangitis, sporotrichotic gum- 
mous, 270 

tuberculous gummous, 269 
Lymphatic leukemia, 651 

varicosities, 696 
Lymphoderma perniciosa, 119 
Lymphogranulomatosis, 653 
Lymphorrhea, 362 
Lymphosarcoma, 653 
Lymph-scrotum, 363 



Microglossia, congenital, 370 
Macular atrophies, 341 
Macules, 23, 322 
Madura foot, 270, 602 
Madurella, 599 
Mai del Pinto, 528 
Malassezia furfur, 529 
Malgache, 301 
Malignant edema, 594 

pustule, 593 
Malleus, 590 
Malum perforans, 302 
of mouth, 308 
plantaris, 303 
Mechanical purpura, 54 
Medicinal acne, 390 

eruptions, 463, 472 

roseola, 25 
Meige, trophedema of, 371 
Melanin, 320 
Melanodermas, 325 

Addisonian, 325 



Melanodermas, pediculous, 329 

phthiriasic, 329 

tuberculous, 325 
Melanosis lenticularis progressiva, 355 

precancerous circumscribed, 665 

progressive cutaneous, 665 
Meleda disease, 271 
Mendacia, 438 
Mercurial stomatitis, 308 
Microbic eczema, 66 
Microsporia, 527 
Microsporon Audouini, 527 

furfur, 530 

minutissimum, 532, 533 
Microsporosis, 114 
Miliaria crystallina, 445 
Miliary abscess of little children, 446 

colloid degeneration of cutis, 359 

impetigo, 87 

syphilides, 619 

tuberculosis of skin and mucous 
membranes, 549 
Milium, 385, 671 
Milks, 717 

Moist erosions of buccal mucosa, 304 
Molluscum contagiosum, 674 

pendulum, 667 
Monilithrix, 418 
Morbus maculosus, 57 
Morphse gutta, 346 

of leprosy, 332 

nostras, 332 
Morphea, 350 

leprosa, 582 
Morphology of the dermatoses, 17, 

23 
Mosquitoes, 507 
Mouth, herpes of, 153 

malum perforans of, 308 

syphilitic chancres of, 307 

"trench," 306 

ulcers of, trophic, 308 
Mozambique ulcers, 301 
Mucous membranes, impetigo of, 167 
keratosis of, 218 
lichen planus of, 227 
lupus of, 558 
ulcerations of, 303 
zona of, 157 

patches, 144, 620 

hypertrophic, 247 
Muguet, 305 
Mycetoma, 270, 602 
Mycoses, papillomatous, 249 
Mycosis fungoides, 657 
Mycotic gummas, 270 
Myeloid leukemia, 651 
Myelomatosis, 652 
Myoma, 692 
Mythomania, 193 
Myxedema, 372 
Myxoma, 692 



762 



INDEX 



N 



Nail, epidermic, 431 
Nail-plate, 430 

Nails, congenital malformations of, 
431 

diseases of the, 430 

eczema of, 435 

hang, 432 

worn-off, 432 
Nasal pruritus, 488 
" Necklace of Venus," 326 
Necrobiosis, 312 
Necrosis, 312 
Neoplasms of buccal cavity, ulcerative, 

309 
Nervous diseases, dyschromias of, 327 

pruritus, 485, 487 
Neuro-arthritic pseudo-elephantiasis, 
371 

pseudolipoma, 371 
Neurodermatoses, 481 
Neuro-fibromatosis, 668 
Neuromas, plexiform, 667 
Nevi, 664 

achromic, 320 

adenomatous, 672 

cellular, 666 

cystic follicular adenomatous, 671 

hairy, 668 

hyperkeratotic, 206 

keratotic, 206 

linear, 206 

molluscum, 667 

pigmentary, 665 

pilosi, 405 

tuberous, non-vascular, 666 

varicose, 206 

vascular, 23, 693 

verrucose, 666, 667 
Nevo-carcinomata, 667, 682 
Nevo-cellular epitheliomas, 682 
Newborn, erythrodermas of, 122 

lamellar desquamation of, 122 
Nile boil, 648 
Nipple, eczema of, 75 

Paget's disease of, 234 
Nits, 502 
Nocardia, 599 
Nodes, 263 

subacute non-gummous, 271 
Nodular dermatoses, 263, 265 

erythema, 24 

lupoid, 260 

syphilides, 271 
Nodules, 263 
Noma, 308 

Non-cicatricial alopecias, 412 
Non-elephantiastic hypertrophies, 371 
Nosology of the dermatoses, 447 
Nummular eczema, 72 

syphilides, 619 



Nurslings, desquamative erythroder- 
ma of, 124 
exfoliative dermatitis of, 123 



Occlusive dressings, 717 
Occupational acne, 390 

dermatitides, 467 

eczema, 65, 467 

keratoderma, 213 

radiodermatitides, 454 
Oidium, 599 
One-year boil, 648 
Onychogryphosis, 431, 43S 
Onychophagia, 432 
Onychomycosis, 433 

favosa, 433 

trichophytica, 433, 522 
Onychorrhexis, 439 
Onychoschizia, 439 
Onychoses, 430 

of the dermatoses, 434 

dystrophic, 437 

of general diseases, 436 

of nervous origin, 437 

traumatic, 432 
Onyxis, impetiginous, 434 

pyococcic, 434 

syphilitic, 436 
Opaline plaques, 620 
Ophiasis, 413 
Ophthalmic zona, 156 
Orbicular eczema, 75 
Oriental boil, 250, 648 
Orificial eczema, 75 
Oroya fever, 593 



Pachydermatocele, 372 
Pachydermic cachexia, 372 
Pachyonyxis, 437 
Pagetoid epithelioma, 681 
Paget's disease of nipple, 234 
Palatine velum, svphilitic gummas of 

268 
Palmar pruritus, 488 

psoriasis, 215 

syphilides, psoriatiform, 216 

trichophytosis, 216 
Paludean pigment, 320 
Panighao, 515 
Papillary dystrophy, 242 

epithelioma, 677 
Papillomata, 670 
Papillomatous dermatoses, 238 

elephantiasis, 246 

epithelioma, 249 

lupus, 554 



INDEX 



763 



Papillomatous mycoses, 249 

sporotrichoses, 249 

toxicodermas, 249 

tuberculosis, 247 
Papular chancre, 615 

dermatoses, 127 

erythema, 24 

patches, 127 

plaques, 127 

roseola, 142 

syphilides, 142, 619 

urticaria, 45 
Papules, 127 

dermic, 128 

epidermic, 127 

mixed, 129 

of prurigo, 140, 141 

of strophulus, 141 
Papulo-circinate syphilide, 144 
Papulo-erythematous erythema, 39 
Papulo-lenticular erythema, 37 
Papulo-ne erotic tuberculides, 398, 566 
Papulo-nummular syphilides, 144 
Papulo-pustular follicular syphilides,398 
Papulo-pustules, 160 
Papulo-squamous follicular syphilides, 
397 

syphilide, 142 

tuberculide, 147 
Papulo-tubercles, 252 
Papulo-vesicular eczema, 72 
Paraffinoma, 276 
Parakeratosis, 64 

variegata, 112 
Parapsoriasis, 111 

guttata, 111 

lichenoides, 111 

in plaques, 112 
Parapsoriatic tuberculides, 564 
Parasites, animal, 502 

vegetable, 502 
Parasitic dermatoses, 502 

eczema, 65 

trichoses, 419 
Parasitophobia, 482 
Paratraumatic eczema, 66, 73 
Parchment-like scleroderma, 346 
Parenchymatous vesiculation, 148 
Pastes, 717 

Pathogenic erythema of Bazin, 27 
Pathomania, 193 
Pediculoides ventricosus, 514 
Pediculosis, 502 
Pediculous melanoderma, 329 
Pediculus pubis, 505 
Pellagra, 32 
Pemphigus acutus febrilis gravis, 179 

chlorotic, 192 

chronic, 186, 188 

congenital, 191 

with tendency to cicatrization 
191 



Pemphigus diphtheroid, 187 
epidermic, of newborn, 168 
foliaceus, 120, 189 
gangrenous, 187 
hemorrhagic, 187 
hystericus, 192 
iodide, 475 
pruriginous, 179 
recurrent, 179 

simple traumatic hereditary, 191 
successif a Kystes epidermiques, 

191 
syphilitic, 177 
treatment of, 189 
ulcerative, 187 
vegetans, 244, 245 
virginal, 192 
vulgaris, 186 
with small bullae, 179 
Peribuccal pruritus, 488 
Perigenital pruritus, 488 
Perionyxis, 435 
Peripheral zona, 156 
Peripilar eczematides, 95 

seborrheids, 395 
Perleche, 540 

Phagedena, chancroidal, 295 
tertiary, 295 
ulcerations of, 293 
Phagedenic ulcers, 281 

of tropical countries, 301 
Pharynx, herpes of, 152 
Phlegmonous acne, 386 
hidrosadenitis, 446 
Phlyctenoses, recurrent, of extremities, 

186 
Phthiriasic melanoderma, 329 
Phthiriasis, 502 
Phthirius inguinalis, 505 
Phthisis, acute buccal, 289 
Pian, 646 
Pian-Bois, 649 
Piedra, 428 
Pigeonneau, 469 

Pigmentary dermatosis of legs, 323 

dystrophy, 242 

spots, 323, 325 

syphilides, 326 

Pigmentations, artificial, 321 

Pigmented erythema, 24 

urticaria, 44 
Pigments, cutaneous, 320 
Pilo-sebaceous follicles, 376 
Pinta, 528 

Pityriasic erythroderma in dissemin- 
ated patches, 173 
favus, 421 
Pityriasiform eczematides, 93 
Pityriasis capitis, 198 
circinata, 90 

lichenoides chronica, 112 
maculata et circinata, 99 



764 



INDEX 



Pityriasis oleosa, 199 
. rosea, 99, 198 

rubra, 118, 198 

pilaris, 120, 198, 399, 564 

sicca, 199 

simplex, 147, 198 

of face and hairless parts, 200 

versicolor, 198, 529 
Pityroid alopecias, 409 
Plantar pruritus, 488 

psoriasis, 215 

syphilides, psoriatiform, 216 

trichophytosis, 216 

warts, 241 
Plexiform neuromas, 667 
Plica, 503 
Poikiloderma vascularis atrophicans, 

344 
Polyadenomas, 676 
Polymorphous acne, 386 

dermatitis, 179 

erythema, bullous, 175 
Porokeratosis, 210, 216 
Port-wine stains, 664, 693 
Posterosive syphiloid, 31 
Postsyphilitic atrophies, 342 
Powders, 714 
Pox, 610 

Precancerous affections, 236, 685 
Premycotic erythroderma, 119 
Presenile dystrophy, 358 
Progressive multiple angiomas, 694 
Proliferating dermatoses, accidentally, 
244 

epithelioma, 249 

pyodermatitides, 246 

tropical dermatoses, 249 
Prurigenetic mnemoderma, 485 

summation, 485 
Pruriginous pemphigus, 179 
Prurigo, 488 

circumscripta, 498 

ferox, 495 

Hebra's, 494 

hiemalis, 497 

lymphadenique, 495 

nodularis, 495 

papules of, 140, 141 

simplex acutus, 492 

summer, 498 

treatment of, 499 

vulgaris, 496 
Pruritus, anal, 488 

artificial, 482 

biopsic, 487 

buccal, 488 

diathetic, 484 

dyscratic, 484, 487 

of hairy regions, 488 

hematogenous, 485, 487 

hiemalis, 484 

localized, 488 



Pruritus, nasal, 488 

nervous, 485, 487 

palmar, 488 

peribuccal, 488 

perigenital, 488 

primary, 483 

plantar, 488 

secondary, 482 

senile, 488 

toxic, 484 

treatment of, 499 

vulvar, 488 

winter, 484 
Pseudococcidias, 231 
Pseudo-elephantiasis, neuro-arthritic, 

371 
Pseudolipoma, neuro-arthritic, 371 
Pseudo-pelade of Brocq, 393 
Pseudoxanthoma elasticum, 358 
Psoriasis, 102 

arthropathia 105 

buccal, 219 

discoides, 102 

dolorosa, 105 

guttata, 102 

infiltrated, 104 

inversa, 105 

inveterata, 104 

lichen, 112 

nummularis, 102 

oozing, 104 

palmar, 215 

plantar, 215 

punctata, 102 

syphilitic, 216 

treatment of, 109 

universalis, 120 
Psoriatiform eczema, 64 

eczematides, 95 

lupus, 554 

syphilides, 113, 216 
Psorospermosis follicularis vegetans, 

231 
Pulex penetrans, 506 
Punctiform keratosis, 216 
Purpura, 52 

of acute infectious diseases, 54 

annularis telangiectodes, 56 

cachectic, 54 

exanthemata, 55 

fulminans, 57, 317 

gastro-intestinal, 55 

hemorrhagica, 53, 57 

mechanical, 54 

primary, 54, 75 

rheumatoid, 54 

secondary, 54 

senilis, 54 

simplex, 53 

toxic, 54 

urticans, 44 
Purpuric erythema, 24 



INDEX 



765 



Purpuric fever, 59 
Pustular dermatoses, 161 

lupus, 173, 555 
Pustules, 160 

dermic, 160 

epidermic, 160 

follicular, 160 

of infectious chronic dermatoses, 
172 
Pyococci, 536 
Pyococcic onyxis, 434 
Pyodermatitides, 467, 536 

proliferating, 246 



Radiodermatitides, 452 

"Rat leprosy," 579 

Recklinghausen's disease, 668 

Recurrent pemphigus, 179 

Red tongue, 228 

Reducing agents, 734 

Reflex erythema, 28 

Regional glandular lymphadenoma, 653 

Reticular atrophy, 344 

Rheumatic nodosities, 266 

Rheumatoid purpura, 54 

Rhinophyma, 374 

Rhinoscleroma, 373 

Rhomboidal glossitis, median, 226 

Rodent ulcer, 281, 682 

Rosacea, 36 

Roseola, antipyrin, 42 

balsamic, 42 

emotional, 25 

of leprosy, 42 

medicinal, 25 

of mycosis fungoides, 42 

papular, 142 

squamosa, 99 

symptomatic infectious, 25 

syphilitic, 41 
Roseolar exanthematic fevers, 25 
Rouget, 513 

Rubeoliform erythema, 25 
"Run-around," 163 



S 



Saccharomyces, 599 
Salek boil, 648 
Salve sticks, 716 
Salves, 716 
Sarcoids, 259, 272 

benign, 259, 272, 564 

disseminated nodular, 273, 564 

hypodermic, 273 

subcutaneous, 564 
Sarcoma, 706 

atypical, 706, 708 



Sarcoma, fascicular, 706 

generalized, 707 

multiple hemorrhagic, 709 

primary idiopathic, 706 

round-cell, 706, 707 

secondary metastatic, 706 

spindle-cell, 706 

typical, 706 
Scabies, 507 

animal, 512 

equine, 120, 512 

Norwegica, 512 
Scabitees ungium, 437 
Scaborrhea, fatty, 383 
Scalp, eczema of, 74 
Scarlatiniform erythema, 25 

recurrent desquamative, 25 
Sclerema, 347 
Sclerodactylia, 348 
Scleroderma, 347 

annular, 352 

in bands, 351 

edematous, 347 

frontal, 351 

generalized, 347 

parchment-like, 346 

partial, 350 

in patches, 350 

progressive, 348 

superficial circumscribed, 346 
Sclero-gummous ulcerations, 288 
Scleronychia, 431 
Sclerosis, cutaneous, 334 
Sclerotic atrophies in spots, 346 

dermatoses, 335 

lichen planus, 137 
Scrofuloderma, 268 
Scrofulo-tubercular gummas, 268 
Scrofulous ecthyma, 170 
Scrotal tongue, 226 
Scurvy, infantile, 55 

sporadic, 55 
Sebaceous cysts, 670 

flux, 383 
Seborrhea, 383 

congestiva, 570 

corporis, 90 

sicca, 198 

steatosa, 383 
Seborrheal eczema, 63 

syphilides, 144 

warts, 208 
Seborrheic alopecias, 409 

cocoon, 383 

filament, 383 

oleosa, 384 

utriculus, 383 
Seborrhoids, 91 
Senile degeneration, 357 

eczema, 65 

pruritus, 488 

purpura, 54 



766 



INDEX 



Senile warts, flat, 208 
Serous cysts, 672 
Serpiginous lupus, 555 
Serum eruptions, 477 
Slough, 312 

Smooth patches of tongue, 228 
Soapy salves, 717 
Soft chancre, 596 

verrucose nevi, 666 

warts, 666 
Solutions, 714 
Soor, 305 
Sphacelus, 312 

Spinocellular epithelioma, 676 
Spirochete pallida, 610 
Sporotrichium, 599 
Sporotrichoses, 605 

papillomatous, 249 
Sporotrichotic gummas, 270 

gummous lymphangitis, 270 
Squamous eczema, 64, 72 

erythema, 24 
Staphylococci, 536 
Staphylococcic impetigo, 167 
Steatorrhea, 383 
Stellate angioma, 695 
Stimulants and rubefacients, 742 
Stomatitis, diphtheroid, 305 

impetiginous, 167 

mercurial, 308 

ulcero-membranous, 306 

Vincent's, 306 
Streptococci, 536 
Streptococcic impetigo, 162 
Strophulus, 45, 492 

papules of, 141 
Sudamina, 445 
Sudoriparous abscesses, 446 
Sulcated tongue, 226 
Summer eruption, 185 

prurigo, 498 
Sunburn, 32 
Sweat, 441 
Sweats, colored, 444 
Sycosis, 378 

of beard, 379 

on hairy scalp, 379 

lupoid, of Brocq, 394 

of mustache, 379 

simplex, 378 

treatment of, 380 

trichophytica, 522 
barbae, 380 
Symmetrical keratoderma of adults, 

212 
Symptomatic infectious roseola, 25 
Syphilides, 613 

acneiform, 398 
peripilar, 396 

annular, 144 

arciform, 144 

bullous, 177, 620 



Syphilides, corymbiform, 398 

en bouquets, 398 

erythemato-papular, 142 

erythematous, 620 

follicular, 396 

granular, 396 

herpetiform, 398 

keratodermic, 619 

lenticular, 129, 142, 619 

lichenoid, 396 

miliary, 396, 619 

nigricantes, 143, 322 

nodular, 271 

nummular, 619 

papular, 142, 619 

papulo-circinate, 144 

papulo-nummular, 144 

papulo-squamous, 142 

pigmentary, 326 

psoriatiform, 216 

seborrheal, 144 

secondary, 619 

of mucosa, 620 

tertiary, 622 

tubercular, 253 

tuberculo-gummous, 285 

tuberculo-ulcerative, 285 

ulcerative, 284, 285, 620 

varicelliform, 390 

varioliform, 398 
Syphilis, 610 

acquired, 612 

congenita tarda, 627 

congenital, 624 

precocious, 625 

experimental, 612 

insontium, 616 

maligna precox, 284 

pustules of, 172 

treatment of, 632 

ulcerations of, 284 
Syphilitic alopecias, 411 

bubo, 612 

chancre, 613 

of genital mucosa, 311 
of mouth, 307 
ulcerative, 283 

ecthyma, 170 

glossitis, 225 

gummas, 267 

of palatine velum, 268 
of tongue, 268 

leukomelanodermas, 332 

onyxis, 436 

patches, 144 

pemphigus, 177 

psoriasis, 216 

roseola, 41 

rupia, 170, 285 

ulcerations, 285 
Syphiloid, posterosive, 37 
Syringocystadenoma, 673 



INDEX 



767 



Tattoo marks, 332 
Teeth, Hutchinson's, 628 
Tertiary phagedena, 295 

syphilides, 622 
Therapeutic notes, 711 

radiodermatitides, 453 
Thrush, 305 
Ticks, 514 
Tinea acuminatum, 424 

crateriforme, 424 

favosa, 420 

imbricata, 528 

microsporica, 421 

tonsurans, 420 

tricophytica, 424, 522 

with large spores, 424 
Tineas, 419 
Tokelau, 528 
Tongue, black, 229 
hairy, 229 

epithelioma of, 221 

erosions of, 304 

excoriation of, chronic superficial, 
229 

geographical, 228 

leukoplakia of, 219 

plaques of, depapillated, 304 

red, 228 

scrotal, 226 

smooth patches of, 228 

sulcated, 226 

syphilitic gummas of, 268 

villous, 229 
Tophi of gout, 702 
Toxic eruptions of internal origin, 472 

pruritus, 484 

purpura, 54 
Toxicodermas, bullous, 177 

papillomatous, 249 
Toxidermas, 456 

from internal causes, 471 
Toxi-tuberculides, 565 
Traumatic alopecias, 408 

bull®, 175 

eczema, 65 

eczematiform dermatitides, 80 

excoriations of genital mucosa, 310 

gangrene, 313 

onychoses, 432 
Trench foot, 35 

mouth, 306 
Treponema pallidum, 610 
Trichoma, 503 
Trichomycoses, 428 
Trichophytic folliculitides, 380 
Trichophytine, 521 
Trichophyton concentricum, 528 
Trichophytons, 520 
Trichophytosis, 519 

disseminated lichenoid, 522 



Trichophytosis of hairless skin, 522 

palmar, 216 

plantar, 216 

of smooth skin, 114 
Trichoptilosis, 418 
Trichorrhexia nodosa, 417 
Trichoses, 404 

dystrophic, 416 

parasitic, 419 
Trichosporosis nodularis tropicalis, 428 
Trichotillomania, 408 
Trophedema of Meige, 371 
Trophic ulcers of mouth, 308 
Trophoneurosis facialis, 354 
Tropical dermatoses, proliferating, 249 

epidermomycoses, 114, 528 

ulcers, 307 
Tubercle, anatomical, 552 

lupus, 553 
Tubercles, 252 

hypodermic, 252 

of leprosy, 258 

leprous, 587 

lupoid, 259 

lupus, 256 
Tubercular leprosy, 583 

syphilides, 253 

ulcer, 288 

fissured, 289 
of genital mucosa, 311 
papillomatous, 289 
Tuberculides, 563 

acneiform, 564 

angiokeratotic, 564 

eczematoid, 564 

erythemato-atrophic, 564 

erythematous, 564 

erythrodermic, 564 

follicular, 398 

hypodermic, 564 

lichenoid, 564 

lupoid, 564 

papulo-necrotic, 566 

parapsoriatic, 564 

pernio, 571 

ulcerated, 291 
Tuberculo-gummous syphilides, 285 
Tuberculo-pustules, 160 
i Tuberculo-ulcerative dermatoses, 253 

syphilides, 285 
Tuberculosis, 546 

frambesiformis, 552 

fungoid, 552 

lymphangitic, 553 

fungosa serpiginosa, 553 

luposa, 553 

miliary, of skin and mucous mem- 
branes, 549 

papillomatous, 247 

pustules of, 172 

ulcerations of, 288 

vegetative, 552 



768 



INDEX 



Tuberculosis, verrucous, 247, 550 
Tuberculous dermatitis, acute, 549 

gummas, 268, 550 

gummous lymphangitis, 209 

lymphangitides, 553 

melanodermas, 325 

ulcer, 291, 549 
Tuberous abscesses of axilla, 544 

angiomas, 093 

non-vascular nevi, 000 
Tubular epithelioma, 079, 082 
Tumors, calcareous, 092 

connective-tissue, 089 

epithelial, 009 

vascular, 089 
Tylosis, essential, 212 

linguae, 219 
Tylotic eczema, 72 
Typhus, angiohematic, 57 



Ulcer, rodent, 281, 082 

tuberculous, 549 
Ulcerated gummous infiltration, 288 

herpes, 284 

tuberculides, 290 
Ulcerations, 277 

acute, 281 

of buccal mucosa, 304 

chronic, 287 

of dermatomycosis, 293 

of genital mucosa, 310 

of glanders, 293 

groin, 251 

of leprosy, 292 

of leukoplakia, 307 

lupus, 290 

of mucous membrane, 281, 303 

of phagedena, 293 

sclero-gummous, 288 

subacute, 284 

syphilitic, 284, 285 
gummous, 287 

tuberculous, 288 
Ulcerative chancre, 015 

dermatoses, 281 

granuloma of genital organs, 251 

neoplasms of buccal cavity, 309 

pemphigus, 187 

syphilides, 020 

secondary, 284 

syphilitic chancre, 283 

tertiary syphilides, 285 

vegetative lupus, 555 
Ulcero-membranous stomatitis, 300 
Ulcers, 290 

Annamite, 301 

erosive, 070 

of mouth, trophic, 308 

Mozambique, 301 



Ulcers, phagedenic, 281 

of tropical countries, 301 

simple, 290 

tropical, 301 

true, 281 

varicose, of leg, 290 
Ulcus cruris, 290 

durum, 013 

epitheliomatosum terebrans, 281 

molle, 590 
Ulerythema centrifugum, 509 

ophryogenes, 402 

sycosiforme, 394 
Urticaria, 43 

ab ingestis, 40 

accidental, 45 

acute, 45 

autotoxic, 40 

bullous, 45, 175 

chronic, 45 

factitious, 49 

gangrenous, 317 

giant, 49 

hemorrhagic, 44 

infectious, 40 

papular, 45 

perstans, 45 

pigmented, 44 

pigmentosa, 703 

treatment of, 48 
Urticarial erythema, 24 

fever, 44 
Urticarism, 43 



Vacciniform dermatitis, infantile, 108 

herpes, 108 
Vagabond's disease, 329 
Varicella, gangrenous, 171, 317 
Varicelliform syphilides, 398 
Varicose eczema, 73 

nevi, 200 

ulcer of leg, 290 
Varicosities, lymphatic, 090 
Varioliform syphilides, 398 
Vascular nevi, 23, 093 

tumors, 089 
Vegetative tuberculosis, 552 
Venereal warts, 238 
Verruca necrogenica, 552 

vulgaris, 240 
Verrucose nevi, 000, 007 
Verrocosities, 237 
Verrucous elephantiasis, 240 

excrescences, 237 

tuberculosis, 247 
Verruga Peruana, 593 
Vesicles, 148 
Vesico-pustules, 100 
Vesicular dermatoses, 149 



INDEX 



769 



Vesicular eczema, 71 

erythema, 24 
Vespertilio, 571 
Vibices, 52 
Vincent's angina, 306 

stomatitis, 306 
Virginal pemphigus, 192 
Vitiligo, 329 

gravior, 582 
Vulvar pruritus, 488 
Vulvar leukoplakia, 220 



W 



War wounds, eczema of, 66, 73 
Warts, common, 240. See Verruca 
vulgaris. 

flat, 127 

juvenile 130, 241 
senile, 208 

plantar, 241 

seborrheal, 208 

soft, 666 

venereal, 238 
Watery pastes, 715 

solutions, 714 
Weeping eczema, 63 
Wens, 671 
Wheals, 43 
White spot disease, 346 

spots of smokers, 219 
Whitlow, 163 
Willan's lupus, 553 
Wilson, leptothrix of, 428 
Wilson's lichen, 131 
Winter pruritus, 484 
Woody phlegmon of aged, 544 



Worn-off nails, 432 

Wounds, war, eczema of, 66, 73 

Wrists, eczema of, 75 



Xanthelasma, 698 
Xanthochromia, 697 
Xantho-erythroderma perstans, 113 
Xanthoma, 697 

congenital, 699 

diabetic, 699 

eruptive, 698 

glycosuric, 699 

pigmentosum, 355 

pilaris, 402 



Yaws, 250, 646 



Z 



Zona, 154 

buccal, 304 

cervical, 156 

chronic, 159 

genito-crural, 156 

hemorrhagic, 155 

idiopathic, 158 

intercostal, 156 

lumbo-abdominal, 156 

of mucous membrane, 157 

ophthalmic, 156 

peripheral, 156 

recurrent, 159 
Zoster fever, 156 



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